Hospital Volunteer Program Form – Fill Out and Use This PDF

8600 Old Georgetown Road

Bethesda, MD 20814

VOLUNTEER APPLICATION

Dear Volunteer Applicant,

Thank you for your interest in our Volunteer Program. More than 500 volunteers contribute more than 65,000 hours of service annually to our hospital. Still, we have many areas in need of volunteer assistance and we do hope you will decide to join our hospital family.

Our volunteers are carefully screened and asked for a specific commitment. Please review the prerequisites and Volunteer Agreement before completing the enclosed application to ensure you can meet the criteria for a Suburban Hospital Volunteer. If you have any questions, please call us at 301.896.3092.

Prerequisites

•Must be at least 14 years old;

•Sign the Volunteer Agreement;

•Attend an onsite, 2-hour screening interview, orientation, and pre-placement; and

•Attend a second interview with a department manager in your area of interest.

To complete this application:

•Please print or type all the information except your signature.

•Sign the Volunteer Agreement. A parent or guardian signature is required if you are under 18 or enrolled in high school.

•Complete all sections of the application.

•Please mail completed application and signed Volunteer Agreement to the Volunteer Services Office at the address above or fax it to 301.896.2108.

A member of the Volunteer Services staff will schedule your initial interview and orientation. Your placement will be finalized after the second interview.

Many thanks for your interest. We look forward to hearing from you soon.

Sincerely,

Pamela M. Fogan, CAVS

Director, Volunteer Services

PLEASE PRINT IN BLACK INK OR TYPE

NAME Last ______________________________ First_____________________________ MI_______

FIRST NAME FOR ID BADGE, if different from above ______________________________________

TITLE Mr. Mrs. Miss Ms E-Mail Address ______________________________________

STREET ADDRESS __________________________________________________________________

CITY __________________________ STATE _______________ ZIP __________________________

PHONE Home (	) __________________________	Work (	) __________________________
School (	) __________________________	Cell (	) __________________________
AGE 14─18 19─29	30─39 40─49 50─59 60─69	70─79	80+ BIRTH DATE _______________

PREFERRED WORK AREA (Circle)				Patients Public Office Undecided Specific Area ________
AVAILABILITY							(Please specify earliest hour to
Number of days per week		1	2 3 4	5	DAY	HOURS	start and latest hour to stop)
Hours per day		4	6	8	Sunday	______________________
Start Date	____________________				Monday	______________________
How long do you plan to volunteer?					Tuesday	______________________
_____ 100 Hours					Wednesday ______________________
_____ One Year					Thursday	______________________
_____ More than one year					Friday	_______________________
_____ Summer					Saturday	_______________________
WORK EXPERIENCE (Paid or volunteer; list current or most recent job first.)
Current Status (Circle one)			Retired	Unemployed	Employed		Student

1.Job Title ________________________________________________ Dates_______________

Company Name_______________________________________________________________

Supervisor_________________________________________ Phone_____________________

Duties______________________________________________________________________

___________________________________________________________________________

Reason for Leaving ___________________________________________________________

2.Job Title ________________________________________________ Dates_______________

Company Name_______________________________________________________________

Supervisor_________________________________________ Phone_____________________

Duties______________________________________________________________________

___________________________________________________________________________

Reason for Leaving ___________________________________________________________

3.Other Jobs (List job titles only.)

______________________________________________________________________________

LANGUAGES SPOKEN

English French Spanish Italian Other: _____________

SKILLS/HOBBIES (Circle all that apply.)
Data Entry	Word Processing/Typing		Filing	Organizing		Telephone
Other _________________________________________________________________________
WHY DO YOU WANT TO VOLUNTEER? (Check all that apply.)
___ Retired		___ Experience			___	Mental Health Referral
___ School Requirement		___ Give Back to Community			___ To Become Employed
Other (Please specify) ___________________________________________________________
EDUCATION	Career Goal ________________________________________________
Currently enrolled? Yes No		Last Grade Completed: 8 9 10 11			12	College Fr So Jr Sr
Name of High School _____________________________________________							Graduated:	Yes	No
Name of College _________________________________________________							Graduated:	Yes	No
Degree/Major(s) __________________________________________________________
Other Training __________________________________________________________________
HOW DID YOU FIND OUT ABOUT VOLUNTEERING AT SUBURBAN HOSPITAL?
___ Employee (Name __________________________)				___ Church Bulletin			___ Patient
___ Newspaper (Name __________________________)				___Montgomery County Volunteer Center
___ Volunteer (Name ___________________________)				___Red Cross		___Radio (Station ________)

Other (Specify) ______________________________________________________________________

HAVE YOU EVER VOLUNTEERED AT SUBURBAN BEFORE?						Yes	No
Year(s) ___________________________________			Name (if different) ___________________
Area(s) ________________________________________________________________________
WILL YOU PARK YOUR VEHICLE AT THE HOSPITAL?					Yes		No
License Plate Number		Vehicle #1 _______________		Vehicle #2 ___________________
EMERGENCY CONTACT
Name _____________________________________			Relation ____________________________
Home Phone (	) _________________________		Work (		) _________________________
HEALTH SURVEY
Date of last TB Skin Test ___________ Reaction: __			Negative (no reaction)			___ Positive (swollen, red)
Check those that apply to you and elaborate, if needed.
____ Back Problems________________________			____ Blind _____________________________
____ Diabetic _____________________________			____	Epilepsy ___________________________
____ Hearing Impaired______________________			____ Mental Health Problems ________________
____ Tuberculosis (TB) _____________________			Other (Specify) ___________________________
I verify the information on this application is correct.
___________________________________________________					_______________________
Signature of Applicant					Date

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FOR OFFICE USE ONLY

REC___________ DVS____________ CL____________ INTERVIEW ____________ / __________________