Birth Date: I reside in Florida: mo./day mo./day All Year 3-6 months per year * I generally arrive: I generally leave EMERGENCY CONTACT

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1 Select: Hospital Ye Olde Thrift Shoppe Musician Group The Villages Regional Hospital, 1451 El Camino Real, The Villages, FL (Phone: ) Please return completed application to the Hospital front desk, Fax to (352) or Scan and to VOLUNTEER PLACEMENT APPLICATION FORM This application is for Volunteer Placement Office (VPO) purposes only and is not valid until received and reviewed by the VPO and Team Member Services Department. Central Florida Health is committed to providing a safe and healthy environment for everyone on campus. Prior to new volunteer orientation and assignment, applicants must pass all applicable background screenings. Application Date: Last Name: First Middle Present Address: Street City State Zip Previous Address: Street City State Zip (if less than 10 years) Home Telephone: Business: Cell: Address: Birth Date: I reside in Florida: mo./day mo./day All Year 3-6 months per year * I generally arrive: I generally leave EMERGENCY CONTACT Name: Relationship: Home Phone: Cell Phone: Volunteer Application Page 1 of 5 Rev: 03/31/2017

2 All questions referring to Central Florida Health include Leesburg Regional Medical Center, The Villages Regional Hospital And all affiliates. How did you hear about the Volunteer Services program with Central Florida Health? Are you a current or past employee of Central Florida Health? Yes No From: (Year) To: (Year) Departure Date: Reason for leaving: Have you filed an application with Central Florida Health within the past 12 months? Yes No VOLUNTEER EXPERIENCE/COMMUNITY AFFILIATIONS Do you have previous volunteer experience? Yes No Community Affiliations? Yes No Please explain: SPECIAL SKILLS, WORK EXPERIENCE, PROFESSIONAL SKILLS, RECREATION/HOBBIES Special knowledge, skills and abilities you wish to be considered. Include work experience, equipment or machines you operate, computer/technology skills, languages (other than English), recreational activities and/or hobbies. Volunteer Application Page 2 of 5 Rev: 03/31/2017

3 ASSIGNMENT OPPORTUNITIES Please note: Areas marked with an * require primarily walking, standing, lifting, pushing, pulling *Retail sales, interface with customers, operate cash register Reception function to assist patients, visitors or staff, prepare charts *Stock supplies, replace linens, serve as patient liaison, clean equipment *Interface with and discharge patients *Inventory/stock/order supplies & nourishments, assist with distribution Greet/escort patients sell tickets/bricks/plaques, assist with community fundraisers Update/stock/inventory library materials; assist with online resources General clerical duties, prepare charts *Escort patients, stock clean equipment Drive hospital golf cart to pick up/drop off visitors, patients and staff to parking lots *Deliver ice/water, run errands, visit patients, prepare charts CRIMINAL HISTORY Have you ever been convicted of a crime, had adjudication withheld, plead no contest (nolo contendere)? (Anything other than minor traffic offenses) Yes No If YES, Date: State: Charge: Dispostion: Arrest(s) and/or Conviction(s) will not necessarily or automatically disqualify an applicant from service but will be considered as part of the overall evaluation of your qualifications and suitability for the assignment sought. The Company will evaluate the nature and gravity of the offense or offenses, the timing of the conviction or completion of the sentence, the nature of the assignment in question and any applicable individualized considerations. Volunteer Application Page 3 of 5 Rev: 03/31/2017

4 AGREEMENT Please initial and sign I certify that the answers given by me for the foregoing questions and statements are true and correct without omissions of any kind whatsoever and hereby grant the hospital permission to verify such answers. I understand that any false or misleading information furnished by me relative to this application shall be considered rejection of my application for further consideration of volunteer services. If accepted for volunteer services, I agree to comply with the rules and policies of this hospital and those of the Auxiliary. I have read and signed the Code of Ethics for The Villages Health System form on the following page. Signature: Date: FOR OFFICE USE ONLY Aurico Authorization Form (18 and Over): Yes No Copy of Driver s License: Yes No (applicable if driving assigned) Teen Volunteers: SSN# for Badge: ID or Driver License # Comments: Volunteer Application Page 4 of 5 Rev: 03/31/2017

5 If accepted as a TVRH volunteer, I agree to: CODE OF ETHICS FOR THE VILLAGES HEALTH SYSTEM VOLUNTEERS Abide by the Standards and Expectations as outlined in the TVRH Auxiliary Membership Handbook and all approved amendments. Hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, guests, staff, other volunteers and all matters pertaining to the hospital. Work without contemplation of compensation or expectation of future employment. Exemplify the Service Excellence Standard at all times by being punctual, conscientious, dignified, courteous, considerate of others and pledge to demonstrate tolerance and respect for all persons. Wear an approved uniform in the prescribed manner and maintain a professional appearance. Expect to work according to the departmental standards, assume certain responsibilities, expect to be accountable for what I do and will refer questions beyond the scope of my position to the appropriate authority. Recognize that I am part of a team and am willing to help develop good teamwork both within Volunteer Services and other departments throughout the hospital. Anticipate being assigned to a service area which meets my needs, assists with the needs of the hospital, is enjoyable to me and be willing to attend orientation and trained in the services I will provide. Adhere to the Volunteer Service department procedures for signing in and obtaining a substitute when I am unable to report for duty. Observe all present and subsequently issued Volunteer Services policies and procedures. I understand that TVRH may revise its policies and procedures at any time. I understand that the campuses of TVRH & LRMC are tobacco/smoke free. I understand that a separate application is necessary if I wish to volunteer my time with the Auxiliary organization of either hospital. I understand that the Volunteer Services Department reserves the right to terminate my volunteer status as a result of 1) failure to comply with policies and procedures; 2) absences without prior notification; 3) unsatisfactory attitude, work appearance; or 4) any other circumstances which, in the judgment of the Volunteer Services Coordinator, would make my continued service as a volunteer contrary to the best interests of TVRH and its patients. I consent to 1) any pre-volunteer testing/screening required by TVRH; and 2) annual health testing and training required by TVRH. I further give permission to TVRH to investigate any and all information concerning my application in order to determine my qualifications. This includes but is not limited to: medical clearance, criminal background checks, employment and personal reference checks. In the event of my resignation or termination, I agree to return the TVRH identification badge issued to me. Signature of Applicant: Date: Volunteer Application Page 5 of 5 Rev: 03/31/2017