Volunteer Application

    
 
Northwestern Medical Center, Inc
P. O. Box 1370 • St. Albans, VT 05478
Volunteer Services - 524-1055


Volunteer Application
   
   
Last NameFirst NameMiddle NameSocial Security Number
     
     






Home Address
City
State
Zip
Home Phone


In case of Emergency Notify:
Phone:
        
Education/Special Training: 

Previous Volunteer Experience: 

Work and Other Experience:   

Have you ever been convicted of a crime (including misdemeanor and felony convictions)? Yes No 
   
Interests, Hobbies, and Skills (please circle): Art, Crafts, Audiovisual, Food Service, Photography, Nursing, Public Relations, Typing, Computers, Collating, Filing, Telephone Contact, Accounting, Bookkeeping, Tours, Research, General Office Work, Retail Sales, Printing, Receptionist, Other
   
   
   


Please provide two references and their phone numbers. These should be individuals you have worked with or individuals who know you personally.   
   



Name:
Phone:



Name:
Phone:


Are You Willing to Be:








Regularly Scheduled

On Call     

Substitute Basis
   
Days Available:













Monday

Tuesday

Wednesday

Thursday

Friday
       



Approximate Hours Available:

 
Confidentiality Statement:
I understand that information I obtain as a result of my volunteer work regarding Northwestern Medical Center, its Patients and Personnel, should remain confidential. Further, I understand that intentional or involuntary violation of confidentiality may result in corrective action, termination, and possible legal action.  



Signature
Date


I certify that all of the information provided on this application and all other information otherwise furnished is true and correct. I understand that any omission, incomplete or incorrect information, false statement or misrepresentation will result in the immediate rejection of my application, or immediate dismissal if I am providing volunteer service. I understand that my acceptance as a volunteer is contingent upon my satisfactory completion of a PPD for the detection of tuberculosis.

I understand that if I am accepted as a Volunteer, Northwestern Medical Center shall be obligated to file a separate written request for the record of my criminal convictions or reports of abuse with the Commissioner of the Department of Aging and Disabilities and that any conditional acceptance as a volunteer is contingent upon satisfactory results of the investigation. I also understand that Northwestern Medical Center may use the services of an outside agency to complete a background check about me and I agree to sign a written release authorizing such a background check if I am conditionally accepted as a Volunteer and I am asked to do so. Information released to Northwestern Medical Center as a result of this request shall not be released or disclosed to any person without a legitimate business reason to know.



Signature
Date