Licking Memorial Health Systems

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Licking Memorial Health Systems - Measurably different...for your health

About LMHS

Physician Opportunities

Licking Memorial Health Foundation

About LMHS > Become a Volunteer

General Information

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Phone: () -

Email:

DOB: (MM/DD/YYYY)

Are you at least 16 years of age?

Yes No

Completed Education:	High School College Post Graduate Degree
Degree(s):

Work status:

Employed Unemployed Retired Homemaker

Last place of employment:

If presently employed, name of company:

Work phone: () -

Position:

Work hours and days:

Have you ever committed, been convicted of, pleaded guilty to, pleaded no contest to or entered a plea to a felony or misdemeanor?

Note: Conviction of a crime is not necessarily grounds for disqualification.

Yes No

if yes, please explain

In an Emergency, Please Notify:

Name:

Address:

Home Phone: () -

Work Phone: () -

Volunteer Availability

Availability:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
a.m.	a.m.	a.m.	a.m.	a.m.	a.m.	a.m.
p.m.	p.m.	p.m.	p.m.	p.m.	p.m.	p.m.
Evening	Evening	Evening	Evening	Evening	Evening	Evening

Comments:

Interest / Skills

Please indicate with a check mark which you would be willing to share as a volunteer.

Clerical Skills:

answering phones	using copier	numerical updating
using computer	alphabetizing	filing
other (specify)

Patient Care Services:

patient escort	messenger service	visit patients	greet patients
other (specify)

Personal Skills:

knitting	crocheting	sewing	crafting
creating art	gift wrapping
other (specify)

Additional skills/comments:
Special area(s) of interest in volunteering:
Would you be willing to volunteer, if called, to help with a special project such as stuffing and labeling envelopes, answering telephones or assisting with fundraising sales?
Yes No
How did you become interested in our program?
What do you hope to gain from you volunteer experience?
Have you volunteered in a healthcare setting before?
Yes No
If yes, describe experience
What about the healthcare setting is appealing to you?
Are there any work activities or conditions you must avoid?

Personal References

Please do not use relatives as references. At least two references for whom you have worked is preferred.

Name:

Occupation:

Address:

City:

State:

Zip Code:

Phone: () -

Email:

The information provided in this application is true in all respects without any willful omissions. I give my consent for a representative of the Volunteer Office to contact the references listed.

As a VOLUNTEER, I would...

		agree to attend the volunteer orientation and train until I am competent to perform the required duties.
		agree to comply with all the rules and regulations of the Hospital and the Volunteer Office.
		understand that I may be dismissed from my duties for willful wrong doing or negligence and/or performing duties outside of my service description.
		agree to call my assigned area or Volunteer Office as soon as possible when I have scheduling changes.
		understand that LMH is not obligated to utilize my services as a volunteer, nor am I obligated to accept the volunteer assignment offered.
		agree that I am performing my duties as a volunteer and am not entitled to compensation.

CONFIDENTIALITY: It is the belief of this Hospital that all medical, financial and personal information pertaining to a patient is confidential and is protected from unauthorized viewing, discussion and disclosure. Therefore, volunteers may review, use or disclose patient information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

By clicking submit, I acknowledge and have read the statements above and agree to abide by the expectations of the Department of Volunteer Services and LMH.

Opportunities for Volunteers are provided without regard to religion, creed, race, national origin, age, sex or disability.