ADENA VOLUNTEER APPLICATION

PERSONAL INFORMATION

First Name

Last Name

Address 1

Address 2

City

State

ZIP Code

Preferred Phone Number

Date of Birth

Year Round Resident

If No, What Months Available

EDUCATION

High School Name, Address and Graduation Date

College Name, Degree and Graduation Date

Post Graduate College, Degree and Graduation Date

WORK STATUS

Choose One

Employed
Unemployed
Retired

Most Current Employer

Provide name, address, phone and years worked.

Skills/Work Experience (Check all that apply)

Accounting
Leadership
Nursing
Computer
Teaching
Manufacturing
Sales
Trades
Other... This choice will expand a text box

What is your preferred location in which to volunteer? (Check all that apply)

Adena Regional Medical Center (Chillicothe)
Adena Greenfield Medical Center (Greenfield)
Adena Fayette Medical Center (Washington Court House)
Adena Pike Medical Center (Waverly)
Adena Cancer Center (Chillicothe)
Adena Hospice (Chillicothe)

IN CASE OF EMERGENCY CONTACT

First Name Last Name

Relationship

Phone Number

Address

Physician

Physician Phone Number

Date of last TB shot

Any limitations related to your health

How Did You Hear About Our Program?

Select a choice

Friend
Newspaper
Brochure
Website
Other... This choice will expand a text box

Have you ever been convicted of a crime?

If "Yes," explain (include year of occurrence):

AVAILABILITY AND BACKGROUND

Please complete the following to determine your availability and for a background check.

Service Area Opportunities (check all that apply):

Working with patients
Reception/Information
Prefer no patient interaction
Exercise/In House Delivery
Retail
Behind the Scenes (clerical, special projects)
Other... This choice will expand a text box

Personal Reference #1 (cannot be a family member)

Personal Reference #2 (cannot be a family member)

ATTESTATION AND CONFIDENTIALITY

Attestation

The information contained in this application is true in all aspects, without any willful omissions. I understand that if this application is false in any way, I will be dismissed without notice regardless of when the false information is discovered.

Read and Initial:

As a volunteer, I:

Agree to complete the volunteer orientation and train until I am competent to perform the required duties.
Agree to complete an annual compliance review and TB screening as well as any additional service specific training that may be deemed necessary.
Agree to comply with all rules and regulations of Adena Health system and to uphold the policies of my volunteer organization.
Understand that I may be dismissed from my duties for willful wrongdoing or negligence and or performing duties outside of my service guidelines.
Agree to call the Volunteer Scheduling Secretary or Director of Volunteer Services as soon as possible when I have scheduling changes.
Agreed to except assignment to a new service area if absent for an extended period of time.

Confidentiality

It is the belief of this hospital that all medical financial and personal information pertaining to a patient is confidential and is protected from unauthorized viewing discussion and disclosure. Therefore volunteers may look at use or disclose patient information only as it relates to the performance of their duties. Any unauthorized viewing discussion or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

Read and Initial:

Signature

Type your name to "sign" your application.

Date

Authorization for a minor:

I have read the above information and give my permission for the application to become a volunteer and to receive the required tuberculin test is required. I will cooperate in saying that my son/daughter fulfills his/her responsibility.

Signature

Type your name to 'sign" your authorization of a minor.

Relationship to minor if not parent

Date

New code

Please type the code above