Volunteer Service at Shands Jacksonville - On Line Application Form

Volunteer Services Application Form

The application will only be considered completed when you have filled in your information and clicked on the SUBMIT APPLICATION button below.

Personal Information

Last Name:	First Name:	Middle Initial:	Suffix:


Street address:	Apartment:	City:	State:	Zip:


Home phone	Daytime phone	Mobile/Pager/Other	Best time to call:
			Morning Afternoon Evening

Email address:	Date of Birth:	Gender:

Emergency Contact Information

Last Name:	First Name:	Relationship


Primary Telephone Number:	Secondary Phone Number:

School and Employment Information

Are you currently employed? Yes No If yes, please complete this information:
Job Title:	Name of Employer:


Employer's Phone Number:	Employer's Work Address::


Highest level of education completed?


Are you currently a student? Yes No If yes, please complete this information:
Name of school:	Educational level completed:	Expected date of graduation:


Do you have relatives employed at Shands Jacksonville? Yes No If yes, please complete this information:
Employee name:	Relationship to you:	Name of employee's department:

Volunteer Service Information

Why do you want to volunteer at Shands Jacksonville?

What do you envision yourself doing as a volunteer?

If you have volunteered at another facility, indicate briefly where, when and what you did:

If you were refered to us by anyone please check the source and let us know their name:

Shands volunteer	Shands patient/visitor	Shands Employee	Friend or relative
Civic club	Place of worship	School	TV or radio
Newspaper	Recruitment Fair	Other
Details:

Please list any special talents, skills or interests:

In which service areas do you prefer to volunteer:

Days available to volunteer (check all that apply):

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Shift available (check all that apply):
     Morning
     Afternoon
     Evening

On what date are you available to begin volunteer service?

References and Background Information

Have you ever been employed or volunteered at Shands Jacksonville or our founding institutions, Methodist or University Medical Centers? Yes No If yes, please tell us what date and position:

Start Date

End Date

Position

List one personal and one business reference that we may contact. No relatives please. If you are a student, you may list one personal and one teacher as references.

Personal Reference Name:

Phone:

Business / Teacher Reference Name:

Phone:

Have you ever been convicted, plead "nolo contendere" (no contest), or had adjudication withheld for any
crime or offense other than a minor traffic violation? Yes No If yes, please list:

Offense	Date	County	State	Disposition

Are you known by any other names? Yes No If yes, please list:

Last Name:

First Name:

Medical History Information

Is there any reason why you would be unable to safely perform your duties as a volunteer? Yes No *If yes, please elaborate:*


Do you have any physical restrictions or health considerations that should be considered prior to placement? Yes No If yes, please elaborate:


Physician to be called in case of accident or illness:
Name:	Phone

Additional Comments

Please use this space to add any additional comments or information:

Volunteer Applicant's Agreement

I certify that the information contained in this application is correct to the best of my knowledge.
I authorize investigation of all matters contained in this application, and agree that any misleading, false or intentional omission of pertinent information would be cause for rejection of my application or cause for dismissal if already placed in the program.
I understand that the individuals that I have listed as personal references will be asked questions concerning my ability, character and reputation.
I understand that volunteer placement with Shands Jacksonville is contingent upon receipt of satisfactory references, background check, health screening and a TB skin test (PPD), as well as satisfactory completion of Volunteer Orientation.
I understand that initial and continuous volunteer placement is at the discretion of Shands Jacksonville Volunteer Services Department.

Additionally, if selected to be a Shands Jacksonville volunteer, I agree to:

Should any information I have reported in this application change at any time during the application process or after placement, I understand that I have a duty to report any and all changes to the Volunteer Services Department.
Abide by the Policies & Procedures of the Medical Center, the Volunteer Services Department and the department and/or program to which I am assigned.
Keep all patient information and hospital business completely confidential at all times.
Strictly adhere to the volunteerservice guideline(job description), and be aware of volunteer limits and boundaries.
Refer any problems, criticisms or suggestions to the Volunteer office.
Carry out assignments according to the schedule agreed upon, and call in advance when unable to work as scheduled.
Maintain a professional appearance and demeanor while on duty, and demonstrate courtesy and consideration of others.
Agree to commit to a minimum of 100 hours of service. (80 for summer student program)
Donate my services to the organization without contemplation of compensation or future employment.
Attend orientation and training, and participate in the hospital’s ongoing inservice programs as necessary.
Uphold the mission, vision and values of Shands Jacksonville Medical Center.

Type in your name in lieu of your signature:

To indicate that you certify the information you are about submit is correct, please type the characters you see below:

letters

When you have completed the application, click "Submit Application".
Once the application is submitted, you will see a confirmation screen and have an opportunity to print your application.

Volunteer Services Application Form

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