2. Once you have completed your application form, we require two (2) non-family members to complete a reference form for you (see attached).

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1 Volunteer Services Thank you for your interest in volunteering and in serving the patients and families of DeKalb Medical. Listed below are the steps in our application process: 1. Fill out our application form (see attached). 2. Once you have completed your application form, we require two (2) non-family members to complete a reference form for you (see attached). 3. You must also submit to a criminal background check. You may either come to the Volunteer Services office to complete the request form (please call to schedule an appointment), or visit a local police station to request your background check. 4. Additionally, we must receive clearance from your personal physician stating that you are able to volunteer (see attached). 5. If applying between the months of October through March, please provide proof of receiving the influenza vaccination within the season. 6. Once you have completed your application form AND we have received both reference forms, criminal background check, and medical clearance from your personal physician, (all within 45 days of receiving your application) you will be contacted for an interview. Please note, if you are a no call/no show for your interview, you will no longer be considered for a volunteer position. 7. At the interview, volunteers must Commit to a minimum of one (1) year of service, four (4) hours per week please note: If you do not fulfill the one year commitment, we are unable to provide you with a letter of recommendation 8. Attend a Peer Interview this will be scheduled, after your initial interview, for a later date 9. If accepted into the Auxiliary Program, volunteers must: a. Submit to and receive a negative result from a T-SPOT blood test for Tuberculosis. These are given here at the hospital (free of charge for volunteers), and must be completed prior to orientation. Please note, the T-SPOT blood test is different from the PPD skin test. b. Submit to and receive a negative test result from a 10-Panel drug screening (provided at the time of the T-SPOT test, also free of charge) c. Attend a two-hour volunteer orientation d. Pay annual dues of $25.00 (collected at orientation)

2 e. Purchase a volunteer uniform, available in the Volunteer Services office, for $30.00 (paid at orientation) 10. Additional Annual Requirements for volunteers: a. Participate in an annual T-SPOT blood test each spring b. Participate in an annual influenza vaccination each fall c. Pay annual dues of $25 each summer All new volunteers are on a 90-day trial period. Please note: Applications are held for 45 days. If you do not complete this process within 45 days, your application will be discarded and you will be unable to re-apply for one year. Applications can be ed to us at Volunteers@dekalbmedical.org, faxed to , or mailed to: DeKalb Medical Volunteer Services Attn: Karen Caughman, Volunteer Coordinator 2701 North Decatur Road Decatur, GA *Please note that the Volunteer Services Department is not affiliated with the Human Resources Department or any facet of employment services. Volunteering is not a pathway to employment. Acceptance into the program does not guarantee employment with the hospital, nor will it enable you to get a job in any department in which you have volunteered. Those seeking such services should contact their respective academic or employment placement services for further referrals on internship/employment training sites. We view volunteering as a long-term commitment and see committed individuals who will be DeKalb Medical Team Members for years to come. Additionally, we do not offer volunteer opportunities for courtordered community service. On behalf of Administration, we appreciate that you have chosen to donate your time to help DeKalb Medical. I look forward to meeting you! Sincerely, Karen Caughman Volunteer Coordinator Enclosures

3 GENERAL INFORMATION Please Print Auxiliary Volunteer Program Application Title: Dr. Mr. Mrs. Ms. Today s Date: Name: (First) (Middle Initial) (Last) Nickname: Sex: F M Date of Birth: Street Address: City: State: Zip: Phone: ( ) Work (optional): ( ) Cell #: ( ) Are you presently employed? If so, where: The following question relates to felonies, misdemeanors, and other offenses. Volunteer Services in its sole discretion will make the final determination whether a crime bears any nexus to your service as a volunteer. Have you ever been convicted of; plead guilty to; plead no contest (nolo contender) to; paid a fine for; or performed community service for any felony, misdemeanor, or any offense? Yes No If yes, please explain: How did you hear about the Volunteer Program at DeKalb Medical? Will volunteering fulfill a community service or school requirement? Yes No If yes, please explain:

4 WORK EXPERIENCE Auxiliary Volunteer Program As a volunteer: As a paid employee: Any special training: INTERESTS / SKILLS Please list any special skills or talents you would like to share. Example: typing or computer knowledge. Foreign Language(s) - Please List: What is your reason(s) for wanting to volunteer at DeKalb Medical? Hospital Campus Preference: DeKalb Medical at North Decatur DeKalb Medical at Downtown Decatur DeKalb Medical at Hillandale Are you interested in: Joining a Committee Serving on the Board Volunteering at Fundraising Events Dates & Times Available:

5 Auxiliary Volunteer Program Requirements REQUIRED INFORMATION Auxiliary Volunteer Program Submit a complete application Provide two letters of reference from non-family members Submit to a criminal background check Submit a medical clearance form completed by your personal physician Provide proof of receiving flu vaccine (if applying between Oct. through March) Interview with a Volunteer Services Staff Member Commit to a minimum of one year of service for four hours per week Interview with Peer Committee members Submit to and receive a negative result from a T-SPOT blood test for Tuberculosis prior to orientation (instructions provided after Peer Interview) Submit to and pass a drug screening (provided during your T-SPOT appointment) Attend a two-hour volunteer orientation Select a specific weekly service area and volunteer schedule Participate in annual T-SPOT blood test each spring Participate in an annual influenza vaccination each fall Pay annual dues of $25 (collected at orientation and due annually each summer) Purchase a volunteer uniform from Volunteer Services for $30 (collected at orientation) All new volunteers are on a 90-day trial period Volunteer Services makes the final decision in placing a volunteer AGREEMENT By submitting this application, I hereby certify that the answers on this application are true and correct and that any misrepresentation or omission of facts, misleading or false information on my part will be grounds for dismissal as a volunteer. I understand that it is my responsibility to learn, understand and abide by all policies and rules of DeKalb Medical, whether they are written or unwritten, and that failure to abide by the policies and rules is cause for discharge. Acceptance as a volunteer is contingent upon satisfactory references, physician approval and verification of the information submitted on this application. I therefore authorize you to make such investigations and inquiries, regarding my employment history, work references, criminal background and others, as you deem necessary in arriving at a decision to accept me as a volunteer. I authorize that all employers; schools or references thus contacted should be released from all liability in answering inquiries related to my application. The Volunteer Services Department is not obligated to utilize your services as a volunteer nor are you obligated to accept the volunteer assignment offered. Volunteer Applicant Signature: (If applying online, please initial. Your submission signifies your agreement.) Please return your complete application and required forms to: DeKalb Medical Volunteer Services 2701 North Decatur Road Decatur, GA 30033

6 VOLUNTEER PROGRAM Date: MEDICAL CLEARANCE FORM Physician Name: Phone Number: Fax: From: DeKalb Medical Volunteer Services Department Fax: Phone: Applicants Name: DOB: Phone Number: Re: Volunteer Service The above named patient has applied to serve as a volunteer at DeKalb Medical. Your name was submitted as their personal physician. PLEASE CHECK THE FOLLOWING: This person has no physical, emotional, or mental limitations, which would interfere with the applicant s ability to function in the hospital environment. Check one: I agree I disagree This person is physically able to transport patients in wheelchairs. Check one: Yes No Please sign this form, and Fax back to the Volunteer Services Department This is not a request for medical records. DO NOT SEND A COPY OF THE MEDICAL RECORD. Your reply will be held in confidence and is an important factor in considering this candidate. Physician s Name (Print) Physician s Signature Date COMMENTS: Sincerely, Karen Caughman Volunteer Coordinator

7 Volunteer Services VOLUNTEER PROGRAM PERSONAL RECOMMENDATION FORM has expressed a desire to join the Volunteer Program at DeKalb Medical. Each applicant must submit two letters of recommendation from a dean, teacher, co-worker, clergyman, or any other unrelated person (over 18 years of age) who knows the individual well. Please write a brief statement of recommendation regarding this prospective volunteer s character, general attitude, dependability, personality and ability to cooperate and follow instructions. An additional page may be used, if necessary. If you have any questions, please contact the DeKalb Medical Volunteer Services Office at or via at karen.caughman@dekalbmedical.org. Thank you for assisting us in this matter. Please Print Name Relation to applicant Home Phone Work Phone Cell Phone Signature: Date: Comments: (Continue on back if more space is needed.) Please put your recommendation form in a sealed envelope and RETURN TO APPLICANT.

8 Volunteer Services VOLUNTEER PROGRAM PERSONAL RECOMMENDATION FORM has expressed a desire to join the Volunteer Program at DeKalb Medical. Each applicant must submit two letters of recommendation from a dean, teacher, co-worker, clergyman, or any other unrelated person (over 18 years of age) who knows the individual well. Please write a brief statement of recommendation regarding this prospective volunteer s character, general attitude, dependability, personality and ability to cooperate and follow instructions. An additional page may be used, if necessary. If you have any questions, please contact the DeKalb Medical Volunteer Services Office at or via at karen.caughman@dekalbmedical.org. Thank you for assisting us in this matter. Please Print Name Relation to applicant Home Phone Work Phone Cell Phone Signature: Date: Comments: (Continue on back if more space is needed.) Please put your recommendation form in a sealed envelope and RETURN TO APPLICANT.

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