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Volunteer Application
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Volunteer Application
If you wish to volunteer, please fill out the forms below and email them to
stmarysvolunteermanager@uhsinc.com
.
Practitioner Disclosure
Practitioner Information
Precheck Release
Are you an adult? (Age 18 or over)
*
Yes
No
Name (Last)
*
Name (First)
*
Address
*
City
*
ZIP
*
Email
*
Home phone
*
Cell phone
*
Birthdate
*
Limitations related to health
*
Note: If you have a physical condition, and/or are taking medication for any condition, please advise us in case of an emergency. All information will be kept confidential.
Work Experience
*
Volunteer experience (list places and dates of service):
*
Education/special training completed
*
School
Hobbies, skills, interests
*
Reason for wanting to volunteer
*
Timeframe you would like to volunteer
*
Note: St. Mary's is unable to offer volunteer opportunities to people seeking short-term service or community service hours.
Select the areas where you may be interested in serving
*
Gift Shop
Information Desk
Surgery Waiting Room
ICU Waiting Room
Short Stay Surgery Area
SaintMobile Transport Program
Notepad/Pen Delivery
List the time/s you would prefer to volunteer each week:
*
Shifts are available every weekday from 8 a.m. to Noon and Noon to 4 p.m.
Do you have available transportation? Yes/No
*
Yes
No
Have you ever committed a crime? If yes, explain.
Note: Conviction does not necessarily disqualify applicant.
Person who referred you to St. Mary's Volunteers
Personal reference
Name
*
Phone Number
*
Emergency contact person
Name
*
Relationship
*
Home phone
*
Cell phone
*
Physician
Name
Phone number
I understand and agree that:
Each time I volunteer, I will wear the appropriate uniform for my service area and my badge. As a volunteer, I will keep all information about patients confidential. I will be reliable and fulfill my service commitment. I understand that if I should misrepresent or deliberately leave out a fact in my application, I may be refused the opportunity to volunteer or may be terminated from the volunteer program.
Signature:
*
Date
*
Year
Year
2021
2022
2023
2024
2025
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Month
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Feb
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Dec
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Day
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