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Direct Placement Application
Pet Therapy - Canine Owner Application
Pet Therapy - Canine Information
Reiki Application
STOP!
Complete this application only if you are a Staff member submitting a volunteer role.
New User Details
User ID
User ID (verify)
Password
Password (verify)
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Contact First Name
Contact = Staff member who will supervise this role.
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Contact Last Name
E-mail address
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Phone (Business)
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Phone (Mobile)
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Your Department
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Department VP
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Title of volunteer role
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Location of volunteer role, i.e. CB2, B5E, JB5 etc.
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Why is this role being created?
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How will this role support your department?
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How will you measure the impact of this role?
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Qualifications/Skills desired
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Role Description/Specific Duties: (PLEASE remember that any function not written in this role will not be covered by the hospitals liability policy if it is performed.)
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First date volunteers needed:
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List days and times needed
Will you allow teens for this position?
Yes
No
If yes, please check age range appropriate for this role
14-18 years
16-18 years
Will this volunteer have any physical contact (three feet or less) with patients?
Yes
No
Will this volunteer have any access to patient medical records?
Yes
No
Will this volunteer be involved in any patient care or treatment decisions?
Yes
No
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I understand it is the responsibility of my department to provide training on age specific competencies, diversity, department specific infection control and safety policies/procedures.
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If computer access is required, the Department of Volunteer Services will provide you with an identification number after the volunteer has been cleared and placed in your department. Each receiving department is responsible to request access for their volunteer.
