Children's Hospital of Michigan- Volunteer Application

Volunteer Application

Personal Information

* Last Name

* First name

* Middle Initial

* Phone (Mobile)

Phone (Home)

* E-mail

* Street address

Apt/Suite

* City

* State

* Zip/Postal

* DOB

Gender

Emergency Contact Name

Relationship

* Phone Number

Area of Interest

Detroit Location Only:

Other (please specify interest/program):

Schedule Preference (Detroit Location Only)

We request a minimum of 100 hours of service and a consistent weekly schedule.
Please check your availability below.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Experience

Past Volunteer Experience:

Organization(s):

Position(s):

Date/Length of Service:

Please tell us about one of your previous volunteer experiences:

Employment Experience:

Current Employer:

Position:

Dates of Employment:

Supervisor's Name:

Phone Number

Can we contact?

* What is your experience with children?

* Please describe a time you have interacted with a group of children. What were your challenges toward success?

* What is your reason for volunteering at Children's Hospital of Michigan?

List three adjectives to describe you as a person:

1.

2.

3.

References

Reference Contact:

* (Please no friends or family)

* Phone Number

* E-mail

Person that referred you to Children's Hospital of Michigan:

Name

Phone Number

E-mail

Education

High School:

Diploma:

G.E.D.:

College:

Degree:

Major:

Name of School(s):

Other, please explain:

Are you volunteering to fulfill academic requirements?

Number of Hours:

By What Date:

Are you a United States Citizen?

If not, can you provide proper documentation?

Have you lived outside of Michigan in the last 5 years?

If yes, where:

Dates:

Are you volunteering to fulfill court requirements?

Have you ever been convicted of a felony or misdemeanor?

Dates:

Describe charges, conviction, and other related information:

DMC/CHILDREN'S HOSPITAL OF MICHIGAN CONFIDENTIALITY AGREEMENT

In consideration for volunteer's access to the DMC/Children's Hospital of Michigan and its various facilities, volunteer agrees as follows:

1. Volunteer will follow the procedures set forth by the DMC/Children's Hospital of Michigan to register himself/herself with CHM Volunteer Services prior to his/her service.

2. Volunteer agrees to be in proper uniform and dress code and to keep his/her DMC identification highly visible during the course of his/her engagement.

3. Volunteer agrees to remain in assigned areas only, unless authorized or accompanied by appropriate DMC personnel.

4. Volunteer understands that he/she may come in contact with 'protected health information' as that term has been defined by the Health Insurance Portability & Accountability Act. Volunteer agrees that he/she will not at any time, either during his/her engagement or thereafter, copy or record that information, or use for his own benefit or divulge, furnish or otherwise make available, either directly or indirectly to any person, firm, corporation or other entity any proprietary or protected health information. Volunteer shall keep all privileged patient-related information strictly and absolutely confidential. This involves no conversation in any public areas such as elevators, parking structure, cafeteria, hallways, etc.

5. I understand that I may be given access codes or passwords to DMC computer systems. I will safeguard the codes and passwords. I am prohibited from disclosing my security codes to anyone including family, friends and other DMC employees.

6. Volunteer, upon the cessation of their engagement or upon termination of service with the DMC, will immediately surrender and deliver to the DMC all lists, books, records, memoranda, documents, data, uniforms and ID of every kind relating to proprietary or protected health information and all other property belonging to the DMC.

7. I understand that failure to comply with any of the stated requirements could be cause for termination, revocation of privileges and access to the DMC. It could also result in notice to my educational institution, my agency or employer.

8. Signed form must be on file at Children's Hospital of Michigan, Volunteer Services, 3901 Beaubien, Detroit, Michigan 48201, (313) 745-1010 office or (313) 745-5654 fax before start of service.

* Signature:

* Date:

I certify that all responses on this document are true to the best of my knowledge. I agree that this information may be verified and references contacted by the DMC Volunteer Services. This will include Michigan State Police and Public Sex Offenders Registry checks. I understand that any misrepresentation of information constitutes cause for separation or termination from service.

* Signature:

* Date: