Volunteer Application Form Your Information 1. Is this application for an adult or a teen? Adult (19 year and older) Teen 2. Name First Last 3. Today's Date MM slash DD slash YYYY 3. Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number 4. Preferred method of contact Email Phone 5. Phone 6. Email* Date of Birth* MM slash DD slash YYYY Emergency Contact 7. Emergency Contact Name First Name Last Name 8. Phone Volunteer Experience and Preferences 9. Previous volunteer experience at Childrens? Yes No If yes, please list year(s) 10. Previous volunteer experience at another hospital? Yes No If so, what areas? 11. Other volunteer experiences 12. Hobbies, skills, or special interests 13. If you need verification of your volunteer hours include the name and address of your organization (i.e. church, college, civic organization) 14. How did you learn about Children’s Hospital & Medical Center volunteer opportunities? 15. Additional information or comments 16. Indicate your preferred day(s) and time(s) to volunteer Mon-Fri Morning Mon-Fri Afternoon Mon-Fri Evening Sat-Sun Morning Sat-Sun Afternoon Sat-SunEvening 17. Service area interest(s) VOLUNTEER STATEMENT OF COMMITMENT: I understand that my services are donated to Children’s Hospital & Medical Center and that there is no payment for the services rendered under the volunteer program. I understand that volunteering at Children’s means a commitment to a specific program and service activities. I understand that staff, patients, and families will depend on me. I understand that if I am unable to attend my shift this will create extra work or reorganization by others instead of helping those who rely on me. CONFIDENTIALITY AGREEMENT: I understand that any information that I may obtain directly or indirectly concerning patients, families, visitors, staff, Children’s Hospital & Medical Center, or affiliates will be held absolutely confidential. If I break confidentially of patients and/or families I may be terminated from the volunteer program. ANNUAL TB SKIN TEST and EDUCATION REVIEW: I understand that I am responsible to complete an annual TB skin test and education review of hospital and service area information. PHOTO RELEASE: I understand that a hospital representative may take photographs of me for publications or volunteer services use during my volunteer time. I have read the above statements. I understand the written information and agree to abide by the rules, regulations and policies of Children’s Hospital & Medical Center, affiliates, and the Volunteer Services Department. I understand that if I do not abide by rules, regulations and policies I may be terminated from the volunteer program. Electronic signature indicates you read, understood, and agree to abide by the items listed above.* Parent / Guardian I have read and understand the above information and hereby give consent for my son/daughter to participate in the Teen Connection Volunteer Program at Children's Hospital & Medical Center of Omaha. Parent / Guardian Signature Parent / Guardian Phone Section For College Students Current Year In School Expected Graduation Date Do you need verification of volunteer hours and/or activity? If yes, please makes sure to provide the name and address of your school in box #13. Yes No School And Department Contact Name and Title Contact Email Note: Documentation form must be provided to Volunteer Services prior to volunteering.
