Healthcare at West Virginia University

Street Address:

Apartment/Address2:

City:

State:

ZIP Code:

Name:

Relationship:

Phone:

Have you ever been convicted of a crime or are you under charges for any offense against the law other than minor traffic violations?

Yes No

If yes, give details:

Prior experience as a volunteer:

How did you become interested in our hospital volunteer program:

Junior Volunteer — 14-18 attending high school.
Student Volunteer — 18+ attending a college/university.
Adult Volunteer — 18+ not attending a college/university.

Please list two professional references along with complete addresses.  Examples: employers, teachers, co-workers, ministers, etc.  If you are a Junior Volunteer, you will need to bring two written letters of recommendation to your interview.  Letters can be from teachers, coaches, ministers, someone from whom you've babysat, etc.
NO RELATIVES PLEASE!

Name:

Title:

Phone:

Street Address:

Apartment/Address2:

City:

State:

Zip Code:

Name:

Title:

Phone:

Street Address:

Apartment/Address2:

City:

State:

Zip Code:

BELIEVING THAT WEST VIRGINIA UNIVERSITY HOSPITALS HAS NEED OF MY SERVICES AS A VOLUNTEER WORKER, I AGREE TO:

Hold as absolutely confidential all information, which I may obtain directly or indirectly concerning patients, doctors or personnel and I will not seek confidential information in regard to a patient.

My services are donated to West Virginia University Hospitals without contemplation of compensation or future employment and given with humanitarian or charitable reasons.

I grant permission for West Virginia University Hospitals Department of Volunteer Services to check the references I have provided.

If I am convicted of a crime other then a minor traffic violation after being hired as a volunteer, I will report this information in writing to Volunteer Services within 24 hours.

I hereby certify that my answers to the above questions are true, complete and correct.

Please note:
* Filing an application does not assure placement since the number of applicants usually exceeds the number of available openings.  The director of Volunteer Services will choose applicants based on personal traits, interview, and qualifications in keeping with the best interest of the hospital.