Application for Volunteer Service at Powers Health

Conditions of Volunteerism
Please read the following carefully before signing.

1. 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.
2. 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.
3. 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.
4. Our selection is not based on race, creed, color, religion, national origin, age, sex, physical or mental disability.
5. 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.

Parental Consent:

I hereby give permission for my daughter/son to volunteer and certify that all information in this application is correct. I give permission for my child to have a PPD test for tuberculosis. I understand that my child cannot begin his/her service until the results of these tests have been confirmed.

Student Commitment:

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.