AHWM - Volunteer Application & Signatures

Education Status/School Status
Are you currently attending school?*

YesNo
Where do/did you attend? (i.e. High School, College, University, Trade Tech School)*
Highest grade completed:*
Field of study:*
Career Goal:*
I AM INTERESTED IN VOLUNTEERING FOR THE FOLLOWING REASON(S):*
I BRING THE FOLLOWING WORK/VOLUNTEER EXPERIENCE AND SKILLS:*

Goals

Describe short-term, long-term goals and what you expect to gain from participation in our program.
Short Term Goals:*
Long Term Goals:*
Expectations Regarding Our Program:*
Is volunteer service required for school credit?*

YesNo
If yes, hours required (If this does not apply to you, please specify “not applicable”):*
By what date do you need to complete hours?*

Volunteer Agreement
I will...
Become familiar with hospital policy and procedures, mission and code of ethics and will uphold its’ philosophy and standards.

Donate my services to the hospital without contemplation of compensation or future employment.

Be punctual and conscientious, conduct myself in a professional manner and do my best in all assignments requested of me.

Keep accurate records of service by recording hours daily on the sign-in sheets with supervisor confirmation (initials). Notify my supervisor and Volunteer Services of any planned absences well in advance.

Ask questions/seek assistance from supervisors when needed.

Maintain a well-groomed appearance with adherence to the department’s dress code policy; ensuring to always wear my uniform and ID while on hospital premises and on duty.

Report any problems or questionable interaction with employees to the Volunteer and Workforce Development Department staff.

Notify Volunteer & Workforce Development Department and assigned supervisor 1 week prior to termination with submission of ID on the last day of service.

I understand the Volunteer Department reserves the right to terminate my volunteer status as a result of

Failure to comply with organizational policy, rules and regulations/

Absences without notification

Unsatisfactory attitude, work or appearance

Any circumstances, as deemed by the department manager, in which my

continued service as a volunteer would be contrary to the best interest of the organization.

I have read, understand, and agree to abide by the conditions stated above.
Volunteer applicant's name:*

First NameLast Name
Today's date:*

MonthDayYear
Volunteer’s signature or parent/guardian signature if volunteer is under the age of 18:*

Clear
Relationship:*

Volunteer applicantParent/Guardian

Confidentiality Statement
Information regarding patient’s medical treatment and/or diagnosis, personal affairs and any charted information is to be treated as confidential. Patient information may only be discussed with the employees directly involved with treatment and information processing personnel who have a need to know. I understand the unauthorized release of confidential information may involve the hospital in legal action. I understand and agree that I will hold in confidence any observations I may make or hear regarding patients, patient families, employees and hospital business.
Volunteer applicant's name:*

First NameLast Name
Today's date:*

MonthDayYear
Volunteer’s signature or parent/guardian signature if volunteer is under the age of 18:*

Clear
Relationship:*

Volunteer applicantParent/Guardian
***A volunteer may be dismissed immediately by the Manager of Volunteer & Workforce Development Department for such a violation.

VOLUNTEER AUTHORIZATION AND CONSENT PHOTOGRAPH AND PUBLICATION
The undersigned hereby authorizes Adventist Health White Memorial (hospital) to photograph or permit other persons to photograph the person whose name appears below. The undersigned agrees that Hospital may use and permit other persons to use the negatives, prints or digital images prepared from such photographs for such purposes and in such manner, as Hospital may deem appropriate, without compensation. The undersigned agrees the photographs may be used for purposes including, but not limited to, dissemination to Hospital staff, physicians, health professionals and member of the public for educational, treatment, research, scientific, public relations, advertising and charitable purposes, and that such dissemination may be accomplished in any manner and that such use is subject only to the following limitations:
Volunteer applicant's name:*

First NameLast Name
Today's date:*

MonthDayYear
Volunteer’s signature or parent/guardian signature if volunteer is under the age of 18:*

Clear
Relationship:*

Volunteer applicantParent/Guardian

Code of Conduct Acknowledgement
I hereby acknowledge the receipt of the revised “Code of Conduct.” I realize that the Code of Conduct contains many of the policies, procedures, rules and regulations (“Policies”) to which I am subject. I further acknowledge that this Code of Conduct supersedes and replaces any inconsistent Policies and all prior Codes of Conduct. I also understand that it is the intent of the Code of Conduct to give me some idea as to the Policies to which I will be subject and that it is not a complete manual. Except as provided in this Acknowledgement, I realize the Policies may change from time to time.

Failure to comply with this Code of Conduct will result in disciplinary action.
Volunteer applicant's name:*

First NameLast Name
Today's date:*

MonthDayYear
Volunteer’s signature or parent/guardian signature if volunteer is under the age of 18:*

Clear
Relationship:*

Volunteer applicantParent/guardian

Receipt and Acknowledgement of Adventist Health White Memorial Volunteer Handbook
This Volunteer Handbook is an important document intended to help you become acquainted with White Memorial Volunteer Services. This Handbook will serve as a guide; it is not the final word in all cases. Individual circumstances may call for individual attention.

Please read the following statement and sign below to indicate your receipt and acknowledgement of the White Memorial Volunteer Handbook.

I have received and read a copy of the White Memorial Volunteer Handbook. I understand that the policies, rules and benefits described in it are subject to change at any time, at the sole discretion of Volunteer Services.

I am aware that during the course of my volunteering, confidential information will be made available to me. I understand that this information is critical to Adventist Health White Memorial and must not be disseminated within or outside of Adventist Health White Memorial premises.

I understand that my signature below indicates that I have read and understand the above statement and have received a copy of the Adventist Health White Memorial Volunteer Handbook.
Volunteer’s signature:*

Clear
Today's date:*

MonthDayYear
Volunteer manager signature:

Clear
Today's date:*

MonthDayYear

PARENT/LEGAL GUARDIAN CONSENT, IF VOLUNTEER IS UNDER 18 YEARS OLD

I give permission for my child to participate in the Volunteer & Work Experience Services program at Adventist Health White Memorial
Volunteer applicant's name:
Today's Date:

MonthDayYear
Please check the boxes:
Signature:

Clear
Should be Empty:

Volunteer Application

Education Status/School Status

Goals

Volunteer Agreement

Confidentiality Statement

VOLUNTEER AUTHORIZATION AND CONSENT PHOTOGRAPH AND PUBLICATION

Code of Conduct Acknowledgement

Receipt and Acknowledgement of Adventist Health White Memorial Volunteer Handbook

PARENT/LEGAL GUARDIAN CONSENT, IF VOLUNTEER IS UNDER 18 YEARS OLD