Volunteer Form AgeNote: Teens will require a parental consent signature on this form. 16-18 (teen) 19+ (adult) Personal InformationThe below information is required and will be used for your application and background check.Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Main Phone(Required)Cell PhoneEmail(Required) Race(Required) Birth Date(Required) Month Day Year Sex(Required) Male Female Education and Work ExperienceEmployment Status Full Time Part Time Other Previous Occupation (if retired) Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Business Phone NumberMay we contact you at work? Yes No Are you a Student? No High School College Full or Part Time Skills and TalentsSkills Retail Cashier Good Customer Service Skills Accomplished Musician Computer Competency Phone Work Interacting with Patients Good with Children Organizational-Detail Work Fundraising Pastoral Care-EME Days and Times Most Often AvailableMonday Morning Afternoon Evening Tuesday Morning Afternoon Evening Friday Morning Afternoon Evening Wednesday Morning Afternoon Evening Saturday Morning Afternoon Evening Thursday Morning Afternoon Evening Sunday Morning Afternoon Evening Person to Notify In Case of EmergencyName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Phone Number(Required)Alternate Phone NumberEmail(Required) Relationship to you(Required) Volunteer HistoryHave you volunteered at another organization? Yes No If Yes, where? Organization Phone NumberWhat Were Your Responsibilities?Have you volunteered at another CHI Health Hospital? Yes No If Yes, where? ReferencesFirst ReferenceName(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Relationship(Required) Second ReferenceName(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Relationship(Required) Volunteer Time DocumentationIs there an agency, school, or other organization that will need documentation of your volunteer hours? Yes No If yes, what is the name of the organization? Organization Address Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Why is the documentation needed? Do you have a record of child abuse or dependent adult abuse?(Required) Yes No If yes, please give a date, location, and disposition of your case. Have you been convicted of a crime (felony or misdemeanor)?(Required) Yes No Photo/Model Release Form(Required)I release CHI St. Gabriel's Health from any responsibility inherent in the use of my photograph(s) in their internal or external publication, or by release of them to the press, for use in magazines, on the internet, etc. I acknowledge that CHI St. Gabriel's Health purpose in using the photo(s) is/are to promote the mission and vision. I understand I will receive no monetary compensation regarding the use of this/these photographs. I agree to the above information.Volunteer Services Background Check(Required)In connection with my application for volunteer services, I authorize any employer, educational institution, law enforcement organization, state and federal government agency, information services bureau and other persons contacted, to release information regarding my character, performance, qualifications, background and reasons for termination of past employment to CHI St. Gabriel's Health. I also authorize the release of my criminal record to CHI Health and its volunteer organization. I release all parties involved in providing said information from any and all responsibility of liability resulting from such investigation. I agree to the above information.Confidentiality Agreement InformationAs an employee, volunteer, student, or other person affiliated with CHI St. Gabriel's Health, you may have access to what this agreement refers to as "Confidential Information.” The purpose of this agreement is to help you understand your responsibility regarding confidential information. Confidential information includes patient, employee, volunteer, student, financial information, and other information proprietary to CHI St. Gabriel's Health facilities or persons. You may learn or have access to some or all of this confidential information through a computer system or through your activities at CHI St. Gabriel's Health. You are required to conduct yourself in a manner which is consistent with CHI St. Gabriel's Health Policies and Procedures. By reading and signing this agreement, you agree to the following: I will use confidential information only as needed to perform my legitimate duties. I will only access confidential information for which I have a need to know. I will not in any way divulge, copy, release, sell, lend, review, alter, or destroy confidential information except as properly authorized within the scope of my assigned duties affiliated with CHI St. Gabriel's Health, and will be held accountable for the misuse or wrongful disclosure thereof. I will not misuse confidential information or carelessly care for confidential information. I will report any activity by individuals whose actions compromise the confidentiality of information to either my department management or the CHI St. Gabriel's Health Information Security Administrator. My obligation under this agreement will continue after termination of my employment, voluntary association, or student experience. At all times during my affiliation with CHI St. Gabriel's Health, I will safeguard and retain the confidentiality of confidential information. I understand that I do not have right or ownership interest in any access, password, or other authorization to confidential information. I will safeguard and not disclose my password or any other authorization which allows access to confidential information. I will be accountable for the misuse or wrongful disclosure of confidential information obtained through the use of my sign-on and password. I acknowledge that I understand and agree that if I should not abide by this agreement, disciplinary actions up to and including termination of my affiliation with CHI St. Gabriel's Health, will result. Signature(Required)Parent/Guardian Signature Quick LinksMyChart Online Bill Payment Make a Donation Send Email to Patient Contact Us
