Novant Health Auxiliary Prince William Medical Center Haymarket Medical Center

Transcription

1 Novant Health Auxiliary Adult Volunteer Application Form (Application 18 Years of Age or Older and not currently enrolled in high school) Once you have completed this application please scan and , drop off, mail or fax it to the volunteer office as follows: Scan and to: Mail/Drop off: Volunteer Services Fax: When we receive your completed application we will reach out to you via phone or to schedule an interview. PERSONAL INFORMATION (please print clearly If we cannot read your contact information we cannot get in touch with you) Date: Name: First M.I. Last (Nickname) Address: Number/Street Apt. City: State: Zip: Date of Birth: mo _/ day Preferred Phone number: ( ) Secondary Phone Number: ( ) Address: AVAILABILITY Please check the day(s) most convenient for you: Sun Mon Tue Wed Thu Fri Sat Morning If you have a preference for a service area and/or location (for more information please review the document titled Volunteer information found on our webpage: please specify below: Afternoon Evening Please enter the date you can start work:

2 BACKGROUND INFORMATION Employment: Are you currently employed? If yes, please provide details: Employer: Company Name Position Supervisor Years Briefly describe your responsibilities: Education: Are you currently enrolled in school? (enter Yes or No) If yes what school: Degree: History: Pursuant to the Code of Virginia all applicants must affirmatively identify any criminal conviction or pending criminal charge whether within or outside the Commonwealth of Virginia. Furthermore, all applicants will be required to provide a sworn statement disclosing any criminal convictions or any pending criminal charges. Applicants are not required to disclose arrests, charges or convictions that have been expunged. Conviction of a crime is not an absolute bar to volunteering. We will take into account the nature and gravity of the offense or offenses, the frequency of the offenses and the interval between them, the time that has passed since the conviction and/or completion of sentence, and the nature of the volunteer work for which the applicant has applied. With that information in mind, please answer the following: Have you ever been convicted of a crime other than a minor traffic violation? (enter Yes or No) Do you have any criminal charges pending against you? (enter Yes or No) If you answered yes to either of these questions, please explain, including the type of crime(s) involved. I certify that the information contained in this Volunteer Application is correct and complete to the best of my knowledge. I understand that may investigate my background by contacting persons or entities identified in my application, or others, or by examining any public records or other available information about me, including conviction records. Furthermore, I understand that I will be required to provide a sworn statement disclosing any criminal convictions of any pending criminal charges. I understand that falsification, misrepresentation or material omission of facts called for in this application will be grounds for disqualification from further consideration or will result in termination of my volunteer position without notice. Signature: Date: For office use only: Volunteer I.D. Number: Date Joined: Hospital Orientation for Volunteers: Starting Date: Assignment: Service Area/Day/Shift: Chairperson Notified of Start: 1/16

3 Reference Forms Please have the two attached references completed. Family members or individuals who share the applicant s household may not serve as references. Upon completion by your references, you may bring them to our office or have the reference mail, or fax the form directly to the volunteer office. Mail to: Volunteer Services Or to: VolunteerNVA@novanthealth.org Or Fax to: When both of the references are completed and turned into the volunteer office, we will call you to schedule an interview.

4 Volunteer Services Personal Reference Request (Family members or individuals who share the applicant s household may not serve as references.) Applicant s Name: Date: The person named above has applied to for a volunteer position. This program requires individuals who are dependable, punctual, motivated, personable, and cooperative. Personal neatness and the ability to accept and follow instructions are also needed. The individual must understand and honor the hospital s policy on patient privacy and must respect and keep confidential all information concerning patients and the hospital. Thank you for your prompt attention to this and please return to the Novant Health Auxiliary Volunteer Office within a week. Instructions: Please evaluate the candidate on each of the following: Characteristic Excel. Good Fair Poor Dependability Punctuality Trustworthiness, honesty, integrity Initiative Respect for others Ability to work as a team player General appearance Ability to problem-solve Flexibility Oral communication skills Written communication skills Should you wish to comment further, please do so on the bottom and back of this form. How long have you known the applicant? In what capacity? May we call you? Best time(s) to reach you. Home phone: ( ) Work phone: ( ) Ext. address: Cell/pager ( ) Printed name: Signature: Mail to: Volunteer Services Department FAX: Comments: 1/27/2016

5 Volunteer Services Personal Reference Request (Family members or individuals who share the applicant s household may not serve as references.) Applicant s Name: Date: The person named above has applied to for a volunteer position. This program requires individuals who are dependable, punctual, motivated, personable, and cooperative. Personal neatness and the ability to accept and follow instructions are also needed. The individual must understand and honor the hospital s policy on patient privacy and must respect and keep confidential all information concerning patients and the hospital. Thank you for your prompt attention to this and please return to the Novant Health Auxiliary Volunteer Office within a week. Instructions: Please evaluate the candidate on each of the following: Characteristic Excel. Good Fair Poor Dependability Punctuality Trustworthiness, honesty, integrity Initiative Respect for others Ability to work as a team player General appearance Ability to problem-solve Flexibility Oral communication skills Written communication skills Should you wish to comment further, please do so on the bottom and back of this form. How long have you known the applicant? In what capacity? May we call you? Best time(s) to reach you. Home phone: ( ) Work phone: ( ) Ext. address: Cell/pager ( ) Printed name: Signature: Mail to: Volunteer Services Department FAX: Comments: 1/27/2016