Please complete the following forms, which are mandatory, to become an IU Health volunteer. Your packet includes the following:

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1 Volunteer Services Dear Applicant: Thank you for your interest in the Indiana University Health Volunteer program for Methodist Hospital, Riley Hospital for Children, University Hospital and IU Simon Cancer Center. The patients, families and staff at Indiana University Health truly appreciate the service our volunteers give. Please complete the following forms, which are mandatory, to become an IU Health volunteer. Your packet includes the following: 1. Application Application must be completed in blue or black ink, signed and dated. If you are under 18, your application also must be signed by a parent or guardian. 2. Reference Forms Reference forms must be completed by two individuals you have known at least one year. They cannot be from relatives. These forms must be returned with your application. 3. Personal Survey The Personal Survey must be completed so that your interests will be considered when we process your application. Incomplete applications will NOT be processed. Application may be mailed to the address listed at the bottom of this page or delivered to a Volunteer Services office at Methodist, Riley or University Hospital. When your application is received, you will be notified by phone and asked to schedule an interview. It typically takes a minimum of three weeks to complete all steps listed below. 1. Application and references: returned to IU Health Volunteer Services. 2. Interview: with a Volunteer Services coordinator. 3. Background Check: all applicants 18 and older are required to pass a background check before becoming a volunteer. It may include, but is not limited to, Sexual Offender and Criminal History & Conviction searches. 4. Health Screen: at the IU Health Employee Occupational Health Services department at our cost. 5. A New Volunteer Orientation: lasting approximately two hours. Thank you again for your interest in the Indiana University Health Volunteer program. If you have questions, please feel free to contact us at A member of our team will be happy to assist you. Sincerely, Dee Rainey Delorise A. (Dee) Rainey Manager of Volunteer Services Indiana University Health Methodist Hospital 1701 N. Senate Blvd., Rm.B123 Indianapolis, IN 46202

2 PERSONAL INFORMATION: Legal Name (Last, First, Middle) 2011 Volunteer Application Please answer all questions. Print legibly. Incomplete applications will NOT be processed. Social Security Number: Street Address: City: State: Zip Code: Home Phone: Work Phone: Date of Birth: (mm/dd/yyyy) ( / / ) Cell Phone: Have you ever been employed by Indiana University Health or an affiliate? Are you under 18 years of age: Yes No Yes No If yes, please list approximate dates. From: To: Have you ever been a volunteer for Indiana University Health? Yes No If yes, please list the following: Location(s): From: To: Do you have a parent or family member employed by IU Health or an affiliate of IU Health? Yes No If yes please list name and relationship: Name: Relationship: HOW DID YOU LEARN ABOUT VOLUNTEERING AT IU HEALTH? (Check the appropriate box) I am a former patient I am a relative of a former patient Print media/ad/commercial Requirement for class/degree/ graduation/observation hours Volunteer fair (Name/location of fair) Employee/Relative (Name of Employee) Volunteer referral (Name of Volunteer) This is for an Internship/Externship/School Program (Name of Program) WHERE DO YOU WANT TO VOLUNTEER? Please indicate your choices by marking them 1 (top choice), 2, or 3. We will attempt to honor your preference, but cannot guarantee that you will be given your top choice. If the IU Health facility you are interested in is not listed, please contact them directly. Methodist Hospital Riley Hospital for Children (Downtown) University Hospital / IU Simon Cancer Center Indiana University Health Hospice Methodist Medical Plaza (Located throughout Indianapolis. We can find one near you) Plaza Location: HealthNet Community Health Center (Located throughout Indianapolis. We can find one near you) HealthNet Location: EDUCATION: Are you a student? Yes No If yes, please list school: City: State: Zip: Please circle the last grade you completed: High School: Diploma GED College: Major: Degree: BA/BS MS/MA PhD Other

3 EMERGENCY CONTACT INFORMATION: Please list at least one person we should contact in an emergency: Name of Contact Relationship Address Phone Please list any medical information that may assist us in the event of an emergency (e.g., allergies to medicines). CRIMINAL BACKGROUND HISTORY: Have you ever been convicted of a felony or misdemeanor? Yes No If yes, please list all convictions and dates below: Conviction: County/State: Date: Conviction: County/State: Date: NOTE: Conviction means you were found guilty by a judge, jury, no contest, or guilty plea in court. A conviction may have taken place even if you did not pay a fine or spend any time in jail or prison. A conviction will not automatically disqualify you from volunteer placement. Indiana University Health policy will determine which convictions disqualify you from a volunteer placement. A misrepresentation may disqualify you from a volunteer position. If needed, please use an additional sheet of paper. EMPLOYMENT HISTORY: Please provide information regarding your work history. List employers beginning with current or most recent. Dates of Employment: May we contact this employer? Name of Company: Job Title: Address: City, State & Zip: Ph:(with area code): Name of Company Job Title: Address: City, State & Zip: Ph: (with area code): PLEASE READ CAREFULLY AND SIGN I certify that the information in this application (and any accompanying documents) is true. I understand that falsification of any information in this application, discovered before I begin volunteering or while I am a volunteer may lead to my termination. I hereby authorize Indiana University Health/IU Health Volunteer Services to verify, obtain copies of records and gather any information pertaining to my submitting a volunteer application with IU Health/IU Health Volunteer Services. My signature on this application authorizes IU Health/IU Health Volunteer Services to request written verification as needed. The receipt of this application does not imply that I will be offered a position as a volunteer. If accepted as a volunteer, I agree to comply with established rules, policies and procedures. This includes, but is not limited to those which relate to confidentiality, employment and universal health precautions. I understand my volunteer position is at the discretion of IU Health /IU Health Volunteer Services and can be terminated at any time with or without cause, and/or notice. Applicant s Signature: DATE: PARENTAL/GUARDIAN PERMISSION REQUIRED for volunteers under 18 years old. I, the undersigned parent or legal guardian of the child named above, do hereby give permission for this child to perform volunteer service with IU Health/IU Health Volunteer Services. Parent/Guardian Signature: Please mail completed application to: Indiana University Health c/o Volunteer Services Methodist Hospital 1701 North Senate Boulevard, Room B123 Indianapolis, IN DATE:

4 2011 Volunteer Personal Survey Last Name First Name Middle Initial Complete this form in blue or black ink and return it with your application. Attach additional comments on another page if needed. 1. Why do you want to volunteer with Indiana University Health? Please explain in detail. _ 2. What type of general opportunities are you interested in? Check all that apply. Placements will be made based on your preferences and IU Health needs. Customer Service Clerical/Administrative Spiritual Open to any Opportunity Limited / Direct Patient Contact 3. Using two or three sentences, please elaborate on your selection(s) above: 4. What are some of the skills/experiences that you bring to IU Health? (For example: computer skills, customer service experience, etc.) _ 5. When are you available to volunteer? Our minimum commitment required is 33 hours over an 11-week period. Please indicate your availability by completing the table below. List the time(s) that you can volunteer each day of the week and be sure to include A.M. or P.M.). Volunteer opportunities are available from 6 a.m. 9 p.m. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Is there anything else you want us to know? (Ex: I do not wish to volunteer at a certain IU Health facility because... )

5 2011 Applicant Reference Form Last Name First Name Middle Initial This form cannot be completed for your child or a relative. All information you provide will be confidential. The above individual is applying for a volunteer position with Indiana University Health. Please be candid in your assessment of the applicant. If needed, please attach additional comments on another sheet of paper. Use dark blue or black ink only. If you have any questions please call our office at When you have completed this form, please place it in a sealed envelope, sign the back flap, and return it to the applicant. 1. How long have you known the applicant and in what capacity? 2. How would you describe the applicant s character and personality? 3. Please describe the applicant s reliability and punctuality. 4. Are you aware of any physical or emotional considerations that would impact the applicant s success as a volunteer? 5. What are the applicant s greatest strengths? What are the applicant s limitations, if any? 6. Please read the following statements about the applicant and indicate your choice based on your experience. Strongly Agree Somewhat Agree Do Not Know Somewhat Strongly Is open to new people and experiences Demonstrates initiative and dedication Is able to follow directions Adapts well to changing circumstances Shows a strong sense of responsibility Works well as part of a team Has strong communication skills 7. To what extent do you recommend the applicant for a volunteer position? No reservations Some reservations Significant Reservations Why: REFERENCE INFORMATION: Your Name (Last, First, MI,): Profession/Title: Telephone: Address: Address: City: State: Zip Code: Signature: Date:

6 2011 Applicant Reference Form Last Name First Name Middle Initial This form cannot be completed for your child or a relative. All information you provide will be confidential. The above individual is applying for a volunteer position with Indiana University Health. Please be candid in your assessment of the applicant. If needed, please attach additional comments on another sheet of paper. Use dark blue or black ink only. If you have any questions please call our office at When you have completed this form, please place it in a sealed envelope, sign the back flap, and return it to the applicant. 1. How long have you known the applicant and in what capacity? 2. How would you describe the applicant s character and personality? 3. Please describe the applicant s reliability and punctuality. 4. Are you aware of any physical or emotional considerations that would impact the applicant s success as a volunteer? 5. What are the applicant s greatest strengths? What are the applicant s limitations, if any? 6. Please read the following statements about the applicant and indicate your choice based on your experience. Strongly Agree Somewhat Agree Do Not Know Somewhat Strongly Is open to new people and experiences Demonstrates initiative and dedication Is able to follow directions Adapts well to changing circumstances Shows a strong sense of responsibility Works well as part of a team Has strong communication skills 7. To what extent do you recommend the applicant for a volunteer position? No reservations Some reservations Significant Reservations Why: REFERENCE INFORMATION: Your Name (Last, First, MI,): Profession/Title: Telephone: Address: Address: City: State: Zip Code: Signature: Date: