Adult Volunteer Profile

The applicant has two submission options. You may either submit the following application electronically or may send the application via regular mail to:

Stormont-Vail Regional HealthCare
1500 SW 10th Avenue,
Topeka, Kansas 66604-1353
Full Name (first, middle, last)
List other names under which your records may be found
Birthday
Address
City
State
Zip
Former Address
City
State
Zip
Home Phone
Work Phone
Place of employment
(if applicable)
Work Phone
Cell Phone (optional)
E-Mail Address
Last Four Numbers of Your Social Security Number
Best days and time
to contact you
Emergency Contact (must be completed)
Name of person to contact
in case of emergency
Relationship to you
Phone
Please list any relatives employed at Stormont-Vail:
Name
Relationship
Department

Indicate the reason you are seeking a volunteer position (check all that apply)

Personal fulfillment

Professional development

Family/friends volunteer

Extra time

Requirement for class/degree

Other

Are there any groups with whom you would not feel comfortable working? Yes No
If yes, who are they?

How long a commitment
can you make?
6 months
12 months or longer
Other

How did you learn about Stormont-Vail?

friend

instructor

clergy

television

poster/flyer

radio
employer co-worker Other
newspaper newsletter

Briefly state what you see as the benefits of volunteer service:

Briefly state what you see as the disadvantages of volunteer service:

List your previous work experience:

List your previous volunteer experience:
List any extra curricular activities which may help in considering your application

Please explain any conditions which may affect your ability to work with others:

Court Referral
Have you been convicted of a misdemeanor or have charges pending?
 Yes No
Have you been convicted of felony
 Yes No
If yes, when?
where?
Stormont-Vail HealthCare conducts background record checks. Failure to divulge complete information may disqualify you from volunteering. However, a conviction will not necessarily disqualify an applicant from applying.
Have you been ordered by a judge to do community service as an alternative to a fine or jail sentence?
 Yes No
If yes, how many hours and
in what amount of time?
Name of Probation Officer
Phone Number

Reference (Two references must be completed and one reference must be a professional
or business contact. Please exclude relatives.)
Name
Address
Phone
Relationship

Name
Address
Phone
Relationship

Is there a particular type of volunteer work in which you are interested (check all that apply)

one-on-one work

no preference

administrative/clerical duties

short term

public speaking/fund raising

long term
working with several people other
leadership position

Skills and Interests

Art

Typing
Crafts Journalism
Computer Other
Clerical

Placement Information

Days

Times
Sunday Mornings
Monday Afternoons
Tuesday Evenings
Wednesday Weekends
Thursday Other
Friday Days unavailable
Saturday

Please read the following carefully and sign below
  1. I affirm that the information provided on this application is true and complete.
    I understand that before I begin my volunteer service, I will complete the application requirements, submit a reference check, attend orientation, and any subsequent training sessions.
  2. I understand that this application does not guarantee a volunteer placement at Stormont-Vail and that if accepted, I will not receive payment for my service.
  3. I further understand by signing this agreement, I give permission to Stormont-Vail to contact references, to check driving and/or criminal background if deemed appropriate. I understand I may have to give additional information to Stormont-Vail to secure such records.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature

Date


Confidentiality Statement

If selected to become a Stormont-Vail HealthCare volunteer, I understand the necessity of maintaining, as privileged and confidential, all information which I may learn about SVHC patients, including, but not limited to, patient diagnoses, courses of care and treatment, prognoses, personal lives, relationships and concerns, family matters and all information contained between patients and SVHC staff, between patients and volunteers, or between physicians, and SVHC staff in regards to any patient.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature

Date


Volunteer Department Use Only
Interview Date
Possible Areas Discussed
Orientation Date
First Day/Training Date
Service Area(s) Assigned
Schedule(s) Assigned
.
HIPPA Training
Infection Control
TB Administered
TB Read Date
Vol. Works #
Aux. Comp
M/A to Applicant
M/A Received
M/A to Employee Health
References Sent
References Received
Background Check
Background Rec.
Name Badge Ordered
Uniform Paid

For additional information or questions, please call Volunteer Services, 785-354-6095

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