Bonnie Butler-Sibbald. Dear Volunteer Applicant:

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1 VOLUNTEER SERVICES Telephone (818) Facsimile Dear Volunteer Applicant: Thank you for your interest in the volunteer opportunities at Glendale Memorial Hospital and Health Center (GMHHC). Please read carefully the enclosed application materials and general information regarding volunteering at our hospital. As a volunteer you will have an opportunity to join our team of people dedicated to high quality patient care. Employees and volunteers at GMHHC are committed to providing services to patients with Humankindness. We honor the individual worth and dignity of each patient and members of their family. Everyone at GMHHC, whether involved in direct patient care, administrative or technical services, remains mindful that each of our roles affects patients and their families in direct and vital ways, no matter how remote from patient care these roles may appear. Volunteering can be fun, but it is also a serious commitment. Therefore, offer your services only if you intend to do your best, have the time and ability to do so, and can accept guidance and supervision with enthusiasm. We receive significantly more applications then we have volunteer positions open, therefore, we may not be able to accommodate your request. Once you have completed the enclosed forms and application please return it to the lobby front desk, or return it by mail. Upon our review, if your application is complete and we will be able to satisfy your request, we will contact you regarding orientation. A letter or will also be sent to you registering you for the next orientation session. After you have attended orientation, you will interview with me on a one-on-one basis regarding your placement requests. If you have any questions after you have read this application, please feel free to contact the volunteer office at. Sincerely, Bonnie Butler-Sibbald Bonnie Butler-Sibbald, M.S., CAVS Manager, Volunteer Services Encl.: application package

2 (818) Facsimilé VOLUNTEER PROGRAM ELIGIBILITY AND REQUIREMENTS The following items must be met in order to participate in our volunteer program, please review them carefully. 1. Volunteer services are donated to Glendale Memorial Hospital and Health Center without the expectation, contemplation of compensation or future employment and are given for humanitarian or charitable reasons. We do not place individuals in volunteer service to be trained for paid positions at our hospital. 2. A minimum commitment of 100 hours of service is required, with a minimum commitment of 4 hours per week. We cannot accept applicants who are not able to volunteer for the minimum amount of required time. 3. You must be able to maintain a regular schedule of at least 4 hours per week for 3 months or more. We will provide, at your request, a report of your hours for school or any other community service requirement, when you have completed 100 hours or more. 4. Applicants are obligated to notify Volunteer Services if they have been convicted of a criminal offense. Applicants must consent to a background screening which will include OIG, criminal history, sexual offender status, Social Security verification. We do not obtain FICO or credit scores. 5. Volunteers must have the ability to keep all patient information, conversations, and observations confidential. 6. Volunteers must demonstrate willingness to help staff, patients, visitors, physicians and other volunteers whenever possible. 7. Volunteers must have the ability to use good judgment in unusual circumstances. 8. Volunteers must be able to speak, read and write in English (knowledge of a second language is a plus). Volunteers in all areas must be able to communicate in a clear, understandable, and courteous manner. 9. All volunteer applicants must demonstrate an appropriate and positive manner of behavior and communications skills with all persons at all times, including guests, staff, vendors, and other volunteers. 10. Volunteers may be required to withstand long periods of walking and standing. 11. Volunteers work under the direction and supervision of paid staff and do not earn or collect a salary from the hospital or department where they volunteer. You must be dependable, honest, and willing to take direction to perform assigned volunteer duties. 12. Volunteers must be reliable. If unable to be present, you are required to call your assigned supervisor and the volunteer office. 13. Volunteers are not to accept tips or gifts from patients and visitors. 14. Glendale Memorial Hospital employees who wish to serve as volunteers during their off hours may do so, but only in capacities which are different from their normal, paid jobs. 15. You must attend the general orientation presented by the volunteer department before you begin volunteering.

3 (818) Facsimilé 16. The application requires that you must obtain a recommendation from someone who has knowledge of your work skills, academic achievements or community service and is not a relative. 17. You must be in good general health. All volunteers must have a TB test annually. Additionally proof of immunization/immunity to Hepatitis B, measles, mumps, rubella and Varicella may be required. If you have an up-to-date immunization record documenting your TB and immunizations you may be able to receive an immediate health clearance You will be required to wear a volunteer uniform. The uniform consists of a colored volunteer polo shirt that you wear with white pants. Your shoes must be white and have a closed toe and heel. You will be required to purchase your own uniform shirt for $20.00 from the volunteer office. All items of clothing and shoes must be neat and clean. Skirts, jeans of any color and shorts are not permitted as part of the uniform. Only white shirts may be worn under the polo shirt. 19. A small amount of jewelry may be worn, for example, a wristwatch, ring, and small pair of earrings. Large hoops or long dangling earrings or heavy chains, are not permitted. 20. Hats, caps, bandanas may not be worn as part of the uniform. Long hair must be tied back. 21. Men must be clean shaven, no mustaches or beards unless by religious exemption. Nails must be kept short and clear of colored nail polish. 22. You will be issued a photo identification badge at the beginning of your volunteer service. The badge must be worn above the waist, attached to the right collar of your volunteer shirt. The ID badge must be visible at all times while you are on volunteer duty. NOTE: We do not place individuals in volunteer service to be trained for paid positions. The above requirements must be met in order to participate in the volunteer program at Glendale Memorial Hospital. Applicants who do not comply with these requirements, or who return incomplete information, will not be invited to participate. Additionally, your status as Volunteer may be terminated at any time if you fail to follow the policies and procedures of Glendale Memorial Hospital, and those of the Department of Volunteer Services. You may also be dismissed for absence without notice, for unsatisfactory attitude, poor work habits, or appearance, and any other circumstances, which could be harmful to the best interests of the medical center, and/or the volunteer program.

4 VOLUNTEER APPLICATION Please Print Volunteer Services (818) Fax TODAY S DATE: DATE AVAILABLE TO START: LAST NAME FIRST MI STREET ADDRESS CITY ZIP CODE HOME PHONE CELL PHONE ADDRESS WORK PHONE DATE OF BIRTH: MONTH DAY YEAR SOCIAL SECURITY NUMBER - required for background check: EMERGENCY CONTACT INFO: NAME ADDRESS RELATIONSHIP CITY STATE ZIP HOME PHONE WORK PHONE CELL PHONE EMPLOYMENT: Current Last Company Address SCHOOL INFO SCHOOL Retired Position Phone ADDRESS PHONE GRADUATION YEAR GPA ARE YOU VOLUNTEERING TO FULFILL A CLASS REQUIREMENT FOR COMMUNITY SERVICE CREDITS? YES NO IF YES, NUMBER OF HOURS REQUIRED REQUIRED DATE OF COMPLETION ARE YOU VOLUNTEERING TO FULFILL EITHER G.A.I.N / SERS / GYA REQUIREMENTS? Volunteers may be asked to assist staff with translating information to patients/families. If you are willing to assist with translation, please complete this section. Language: Can you read/write in this language? Yes No Language: Can you read/write in this language? Yes No

5 How did you learn about the volunteer program at Glendale Memorial Hospital? Previous or current volunteer experience? How long are you willing to volunteer? 3-6 mos mos. 12 mos. or more Volunteer shifts are in blocks of 4 hours - Sun thru Sat 8am to 8pm Please circle the days, and indicate the time of day, you would like to volunteer: SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY TIME Preference of Volunteer Service: Patient Care Clerical/Office Support Department: Skills or Experience: Do you have family of friends who work or volunteer in our medical center? Yes No If so, who? Where? VOLUNTEER AGREEMENT AND CERTIFICATE OF INFORMATION Believing that Glendale Memorial Hospital and Health Center (herein referred to as GMHHC) has need of my volunteer services I agree to: Hold as absolutely confidential all privileged, and or sensitive information, which I may obtain directly, or indirectly concerning Glendale Memorial Hospital and Health Center, its patients/families, staff and volunteers. Donate my personal time to Glendale Memorial Hospital and Health Center without contemplation of compensation, or future employment. I certify that the answers given by me to the foregoing questions and statements are true, correct, and without omissions. I authorize GMHHC to investigate and or verify the foregoing information, and any other information, which might assist them in determining my qualifications for volunteering. I release GMHHC and my former employers, and all others from liability from damage that may result from such investigation, if upon, such investigation, anything contained in this application is found to be untrue. I further agree to comply with the policies and procedures, as well as safety practices in all areas of GMHHC. I understand that my volunteer status may be terminated at any time for failure to comply with policies and procedures of GMHHC including those of the Volunteer Services Department, for absence without notification, for reasons of unsatisfactory attitude, work, personal appearance, and for any other circumstances which, in the judgement of GMHHC would make my continued service as a volunteer contrary to their best interests. ANY PERSON WHO KNOWINGLY GIVES FALSE INFORMATION WILL BE SUBJECT TO IMMEDIATE DISMISSAL. A criminal record does not automatically disqualify you to be a volunteer at GMHHC. Are you obligated to fulfill court ordered community service? YES NO Have you ever been convicted of a criminal offense (Misdemeanor or Felony)? YES NO Do you have any charges pending against you which are unresolved? YES NO Explanation to each question marked YES: SIGNATURE AND DATE:

6 (818) Facsimile Volunteer Applicant Reference Information Please obtain a reference from someone who is not related to you. APPLICANT S NAME REFERRAL S NAME RELATIONSHIP TO APPLICANT: REFERRAL S ADDRESS REFERRAL S PHONE SIGNATURE: DATE: APPLICANT S ASSOCIATION WITH REFERRAL: Academic Knowledge of Applicant Personal Recommendation (Church, Physician, Family Friend) Knowledge of Applicant s Work and/or Community Volunteer Experience REFERRAL TO FILL IN THE REMAINING PORTION OF THIS FORM: Please make a statement regarding the applicant in the area checked above. Additional page(s) may be added if necessary.

7 (818) Facsimile Personal Statement Name: Date: (Attach additional sheets if necessary) 1. Why are you interested in volunteering at Glendale Memorial Hospital? 2. What do you expect to gain from this experience? 3. Please describe your short-term goals. 4. Please describe your long-term goals. Signature: Date: