Powers Health Adult Volunteer Application

Application for Volunteer Service at Powers Health

Preferred Hospital to Volunteer Community Hospital St. Catherine Hospital St. Mary Medical Center Powers Health Rehabilitation Center Name Address City/State/Zip Code Phone Date of Birth Email Are you a US Citizen? Yes No Have you ever been convicted of a felony? Yes No If yes, give details Service area of interest (ie. information desk, gift shop, clinical areas, etc.) Please state your availability each day (Mon - Sun, Morning, Afternoon or Evening) Do you have any restrictions that might affect your volunteer placement with Powers Health? Current/Previous Work Experience Volunteer Experience Education/Special Training Skills Accomplishments/Hobbies Community Affiliations Who or what encouraged you to volunteer? References (no family members). Please include address and phone number. List any friends or relatives employed or volunteering within Powers Health Emergency Contact Name and Relationship Emergency Contact Address and Phone

I authorize my references to provide information to Powers Health that is relevant to my volunteerism.

Powers Health is dedicated to providing quality health services, providing compassionate care of body, mind and spirit, and delivering superior service to our patients, families and visitors.

I also agree to respect the dignity and rights of each individual and maintain all information in the strictest of confidence. I understand that violations of any policy of Powers Health may result in the immediate dismissal from the Volunteer Program.

I understand that volunteerism is subject to conditions of the Drug Free Workplace Act of 1988.

Conditions of Volunteerism
Please read the following carefully before signing.

I hereby certify that all entries on this application are true and complete and I agree and understand that any falsification of information herein, regardless of time of discovery, may be cause for termination. I understand that all information on this application is subject to verification. Submission of application does not automatically ensure placement.
If placed, I will be required to have a health assessment and my continued volunteerism will be subject to my ability to satisfactorily perform the duties of responsibilities of my position.
Furthermore, if placed, I hereby agree and stipulate that I am an employee as that term is defined under the Worker’s Compensation Act of Indiana.
Our selection is not based on race, creed, color, religion, national origin, age, sex, physical or mental disability.
In accordance with state and federal laws, I will be reference checked for a criminal history. History of felony conviction may disqualify me from volunteerism with Powers Health.

I have read the foregoing conditions of volunteerism and I agree to comply with the terms and conditions therein.

In addition, I authorize investigation of all statements contained in my application. I hereby authorize former employers and educational institutions, licensing boards and authorities, their officers, agents or employees to furnish any information concerning my previous employment/ volunteer record, job performance and character, and hereby release them from liability for reason thereof.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature Date