Volunteer Application

Dear Prospective Volunteer:

Thank you for your interest in volunteering at Parkland Medical Center. Volunteers provide service in a variety of areas of the hospital and are an integral part of our community. The information you provide will be stored in confidence. Your completed form will be held securely and confidentially.

Items to consider:

• Parkland Medical Center has a policy of conducting background investigations for all volunteer applicants prior to beginning a volunteer experience.
• Minimum commitment is 3-4 hours per week for 6 months.
• Minimum age is 14 years old.
• Before starting service, all applicants will be referred to the Occupational Health Department for medical clearance (flu shot and applicable immunizations).
• All applicants will be required to attend orientation and training.
• Please complete all applicable information on the Volunteer Application.
• Falsification of information on either the Volunteer Application may be grounds for denial of a volunteer placement.
• Parkland Medical Center is not obligated to provide a volunteer placement, nor is the applicant obligated to accept a position, if offered.

All fields with an asterisk (*) are required.

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Fields

Contact Information

Name*

First Name*

Last Name*

Address*

Address Line 1

Address Line 2

City

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ZIP Code

Phone*

Birthdate*

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Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Email*

Availability

How did you find out about our volunteer program?

Reason for volunteering?

When are you available for volunteer service?

Totally Flexible Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Saturday Morning Saturday Afternoon Saturday Evening Sunday Morning Sunday Afternoon Sunday Evening

How long do you intend to volunteer? (minimum commitment of 6 months or 2 semesters)

Background

Your Occupation

Your Current Employer

College Graduate

Yes No

If Student, School Attending

Grade

Degree Pursuing

Assignment Preference (check all that interest you)

Administrative Support Volunteer Services Office Hospitality and Magazine Cart Patient Care Units Patient Visits Music or Art Therapy Reiki or Yoga Instructor Spiritual Care Emergency Department Pet Visitation Information Desk

Special Skills or Qualifications

Musical Instrument Graphic Design Recruitment Social Work Financial Accounting Arts and Crafts Team Leader Receptionist Yoga or Fitness Event Planning Photography Nursing Computer Experience Cooking Florist Administrative Public Speaking Chaplaincy

Previous Work and Volunteer Experience

Emergency Contact

Name*

First Name*

Last Name*

Phone*

Email

Two References (not related to you)

Reference 1 Name

First Name

Last Name

Reference 1 Phone

Reference 1 Email

Reference 2 Name

First Name

Last Name

Reference 2 Phone

Reference 2 Email

Agreement and Signature

I understand and agree that submitting this application form does not automatically register me as a Parkland Medical Center volunteer, and that placement as a volunteer is based on current needs matching my skills. I also understand that there are certain additional qualifications I must meet, including a background check, hospital orientation, health clearance (flu shot, immunizations) and the acceptance of established volunteer policies and procedures before I may begin volunteering.

Please check after reading each statement and then sign and date:

I hereby apply for volunteer service with Parkland Medical Center. I voluntarily give this institution the right to check my references and verify past employment or volunteer work.

I hereby state that all information given by me in this application is true.

I hereby state that all information given by me in this application is true.

I understand and agree to comply with the requirements and regulations of the hospital, and to consider all privileged information concerning the hospital, its patients or staff strictly confidential. I will take all criticisms or problems to the Manager of Volunteer Services.

I understand and agree to comply with the requirements and regulations of the hospital, and to consider all privileged information concerning the hospital, its patients or staff strictly confidential. I will take all criticisms or problems to the Manager of Volunteer Services.

Name

Date/Time

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Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

2024

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