Adult Volunteer Application

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1 Adult Volunteer Application Thank you for your interest in s Volunteer Program. Volunteers play an important part in our hospital s effort to deliver quality healthcare to the children of East Tennessee, Southeastern Kentucky and Southwestern Virginia. The generosity of community volunteers has supported in its mission to provide the best possible care for our patients and their families, no matter their ability to pay, since Volunteer positions are available in patient care areas, customer service/retail areas, and clerical/ office areas. New volunteer placements are based on availability and appropriateness of the applicant to the volunteer program and will be determined by the Volunteer Services and Programs Department based on the information you submit, a personal interview, and a criminal background check. In order to begin the application process, please complete and return the following forms: Volunteer Application Pages 2-3 Reference Sheets (2) Pages 4-5 Note that your two references should mail their completed reference sheets directly to us at the address below. We will match them with your application. We recommend providing your references with stamped addressed envelopes. When we receive your application and your two reference sheets, we will move forward with the application process. Volunteer Services and Programs After receiving your information, a representative of the Volunteer Services and Programs Department will contact you to let you know your next step in the application process. is our most utilized contact route. If you do not have an address, you will be contacted by mail or phone. Please note the application process takes approximately four to six weeks. Thank you for your desire to be of help to our children, their families, and our staff. If you have any questions, please do not hesitate to contact us at (865) Form No page 1 of 5 (06/16)

2 Section I Personal Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Home Phone: Work Phone: o Check here if we can call you at work Address: Employer: Cell Phone: Occupation: Are you a student? If yes, school/college: Major: Please check the days and specific shifts you would be available for a volunteer assignment. (Typical shifts: Morning 8:30 a.m. - 12:30 p.m., Afternoon: 12:30-4:30 p.m. and Evening: 4:30-8:30 p.m.) Sunday Monday Tuesday Wednesday Thursday Friday Saturday o Morning o Morning o Morning o Morning o Morning o Morning o Morning o Afternoon o Afternoon o Afternoon o Afternoon o Afternoon o Afternoon o Afternoon o Evening o Evening o Evening o Evening o Evening o Evening o Evening Please select the type of volunteer activity you are interested in: o Arts and Crafts - Help patients and siblings with craft activities in waiting areas. o Child Life - Provide positive, nurturing play experience for patients; also responsible for cleaning toys and playrooms. o Critical Care Lounge - Greet families on the Critical Care floor and offer comfort items. o Cuddler - New volunteers are not eligible; you must first complete 90 hours in another service area at Children s Hospital. o Family and Friends Cart - Visit patient rooms to offer comfort items to families. o Gift Shop - Provide assistance in a retail setting while interacting with patients, families, guests and staff. o Information Desk - Provide general information about Children s Hospital to our guests and assist Admitting staff. o Movie Cart - Visit patient rooms to offer age-appropriate DVDs to patients and families. o Pediatric Medical Library - Assist in reshelving books and helping to maintain the library. o Surgery Lounge - Volunteers assist parents and family members as they wait for their children who are in surgery. If a position is not available in your area(s) of interest when your application is received, your application will be kept on file for one year and reviewed for a match within that one-year period. Please answer the following questions: 1) Children s Hospital Volunteers are required to receive a flu vaccination when volunteering during the months of November through April. The flu vaccine is administered free of charge to volunteers. Would you be willing to receive a flu vaccination? 2) Children s Hospital Volunteers are required to commit to a weekly four-hour volunteer shift (same day/time) for at least six months. Are you able to volunteer weekly for at least six months? 3) Children s Hospital Volunteers are required to submit MMR (measles, mumps, rubella) vaccination records. Could you provide documentation of your MMR vaccination history? 4) When would you be available to start?, Volunteer Services and Programs,, Knoxville, TN Form No page 2 of 5

3 Section II Volunteer Interests and Experience Why would you like to volunteer for Children s Hospital? What do you enjoy most in a volunteer assignment? What do you wish to avoid? Are there any specific interests that you wish to pursue as a volunteer? Please list any applicable education or work experience that you have: Please list any additional skills we might like to know about (i.e. foreign language skills, musical talents): Please list any other volunteer experience you may have: Name of Organization Dates Section III - Background Reference A background check will be performed upon acceptance into this volunteer program. Have you ever been convicted of a felony or misdemeanor? o No o Yes If yes, please complete the following for each: Offense: Date: Location: Disposition: Explain: Conviction records will not necessarily be a bar to volunteer opportunities. Factors such as age at the time of offense, seriousness and nature of the violation and rehabilitation will be taken into account. Permission to Verify Content I (applicant) hereby authorize verification of all statements herein and release Children s Hospital and all others from liability in connection with same. Applicant s Signature Date, Volunteer Services and Programs,, Knoxville, TN Form No page 3 of 5

4 has applied to to be a volunteer. It is mandatory that all applicants submit two (2) references. Please return this form to the Volunteer Services and Programs Department as soon as possible. The application will not be processed until reference forms are returned. Please rate the applicant in each of the categories. Volunteer Services and Programs, Adult Volunteer Application- Reference Sheet #1 Category Volunteers must be on time for each shift. How would you rate the applicant s promptness? Volunteers must be able to attend their shift every week. How would you rate the applicant s reliability? Volunteers must be self-starters. How would you rate the applicant s initiative? Volunteers experience a wide range of situations in the hospital. The ability to make sound decisions is essential. How would you rate the applicant s judgment and emotional maturity? Volunteers communicate with patients, families, visitors, and staff while on duty. How would you rate the applicant s communication skills? Volunteers should be caring, helpful, and positive. How would you rate this applicant s demeanor? Volunteers may have to be corrected while on duty. How would you rate the applicant s ability to accept correction? Volunteers must be able to work with little to no supervision. How would you rate the applicant s ability to work independently? Volunteers must understand and adhere to Children s Hospital s policies and procedures, including strict confidentiality. How would you rate the applicant s ability to follow policies and procedures? Volunteers must follow specific instructions in their service area. How would you rate the applicant s ability to follow instructions? How would you rate the applicant s ability to work with children? Not Observed Excellent Very Good Average Fair Poor Please state why this candidate would or would not be a good candidate to volunteer at Children s Hospital. Your comments are valuable to us and will remain confidential. Please Print Name Relationship to Volunteer Applicant/# of Years Known Signature Date Phone Number Form No page 4 of 5

5 Volunteer Services and Programs, Adult Volunteer Application- Reference Sheet #2 has applied to to be a volunteer. It is mandatory that all applicants submit two (2) references. Please return this form to the Volunteer Services and Programs Department as soon as possible. The application will not be processed until reference forms are returned. Please rate the applicant in each of the categories. Category Volunteers must be on time for each shift. How would you rate the applicant s promptness? Volunteers must be able to attend their shift every week. How would you rate the applicant s reliability? Volunteers must be self-starters. How would you rate the applicant s initiative? Volunteers experience a wide range of situations in the hospital. The ability to make sound decisions is essential. How would you rate the applicant s judgment and emotional maturity? Volunteers communicate with patients, families, visitors, and staff while on duty. How would you rate the applicant s communication skills? Volunteers should be caring, helpful, and positive. How would you rate this applicant s demeanor? Volunteers may have to be corrected while on duty. How would you rate the applicant s ability to accept correction? Volunteers must be able to work with little to no supervision. How would you rate the applicant s ability to work independently? Volunteers must understand and adhere to Children s Hospital s policies and procedures, including strict confidentiality. How would you rate the applicant s ability to follow policies and procedures? Volunteers must follow specific instructions in their service area. How would you rate the applicant s ability to follow instructions? How would you rate the applicant s ability to work with children? Not Observed Excellent Very Good Average Fair Poor Please state why this candidate would or would not be a good candidate to volunteer at Children s Hospital. Your comments are valuable to us and will remain confidential. Please Print Name Relationship to Volunteer Applicant/# of Years Known Signature Date Phone Number Form No page 5 of 5

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