Volunteer Application Form - Grand View Health

Name *

First Last

Address *

Street Address Street Address 2 City State ZIP Code

Date of Birth *

Preferred Phone Number *

Email Address *

All correspondence will be through email

Is this your? *

Cell
Home
Work

Please indicate if any of the following describe you:

Employee / Former Employee of Grand View Health
Auxiliary Member
Veteran
Community Member
College Student
Junior Volunteer

What branch of the military are you in? *

Current / Recent Occupations / School Currently Attending *

How did you hear about the Volunteer Program? *

If "Other", please describe *

Why are you interested in volunteering at Grand View? *

Volunteer Experience *

What skills can you share through volunteering and / or what are your hobbies? *

Please check all of your areas of interest *

Office Support (filing, scanning, data entry, mailings, assembling packets)
Public Engagement (greeter, wayfinding, etc.)
Patient Interaction
Gift Shop / Thrift Shop
Therapy Dog Program (Dog must be certified / insured therapy dog)
Hospice (compassionate support for patients at end of life and their caregivers)
Auxiliary (community representatives, fundraising)
Golf Cart Shuttler for Patients & Visitors

What musical instruments do you play, or what other type of artistic expression can you share? *

Do you have any limitations which should be considered in your volunteer assignment? *

Yes
No

If yes, please explain? *

Criminal Background

Have you ever been convicted of, pleaded guilty or nolo contendere to, or otherwise been found guilty of a misdemeanor or felony offense? (Do not include convictions that have been sealed, erased, statutorily eradicated, expunged or annulled by a court or by a youthful offender adjudication or convictions that resulted in a referral to and participation in a diversion program. Your conviction records will not automatically eliminate you from consideration for volunteering). *

Yes
No

If you answered yes, please explain? *

Have you ever been criminally charged or convicted for a crime related to health care or been debarred, excluded or ineligible to participate in federally funded programs or been proposed for exclusion or debarment? *

Yes
No

Application Certification and Consent

Please read the following carefully before signing:

I certify that the information in this application is true and correct to the best of my knowledge, and I understand that false statements or omissions of fact are sufficient grounds for not being accepted as a volunteer, or termination after acceptance into the volunteer program.

I voluntarily give Grand View Health the right to make a thorough investigation of my past employment, education, background clearances, and activities, and agree to cooperate in such investigation. I furthermore release from all liability and responsibility all persons, companies, or corporations supplying such information to Grand View Health regarding my past employment, education, and activities. I release, indemnify and hold harmless Grand View Health from and against any and all liability which might result from making such an investigation.

I understand that I must comply with all Grand View Health Volunteer Service Department policies and procedures. This includes and is not limited to compliance with the flu policy and immunization procedures. A copy of which can be obtained upon request.

My typed / signed name below shall have the same force and effect as my written signature. You will receive a confirmation message after you click submit. If you do not see this message, your application has not been properly submitted.

Applicant's Signature *

Phone

This field is for validation purposes and should be left unchanged.