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ST. FRANCIS HEALTHCARE SYSTEM VOLUNTEER PROGRAM APPLICATION We

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ST. FRANCIS HEALTHCARE SYSTEM
VOLUNTEER PROGRAM APPLICATION
We are a Catholic Healthcare System in Hawaii committed to creating healthy communities in the spirit of
Christ’s healing ministry. Applicant's Initials: ___________
LAST NAME_________________________________
FIRST NAME_____________________________ MI______________
ADDRESS____________________________________________________________________________________________
Street City ZIP
MAILING ADDRESS___________________________________________________________________________________
PHONE: Residence______________________
Business__________________________ Cell________________________
Email Address______________________________
BIRTH DATE_____/_____/_______S.S.# ____________ _________
(MO/DAY/YEAR)
LIST OTHER NAME(S) YOU HAVE BEEN KNOWN BY OR HAVE USED______________________________________________
HOW DID YOU HEAR ABOUT OUR ORGANIZATION? _________________________________________________________
WHY DO YOU WANT TO VOLUNTEER WITH US? _____________________________________________________________
__________________________________________________________________________________________________
YOUR CURRENT EMPLOYER or SCHOOL___________________________________________________________________
CIRCLE LAST GRADE COMPLETED: HIGH SCHOOL 9 10 11 12 COLLEGE 1 2 3 4 Major _______________
USE ADDITIONAL SHEET IF NECESSARY. PREVIOUS VOLUNTEER OR WORK EXPERIENCE (You may list the courses you are
currently taking in school):
1.__________________________________________________________________________________________________
2.___________________________________________________________________________________________________
3. _______ __
LIST INTERESTS/HOBBIES, ETC.
___________________________________________________________________________________________________
PLEASE LIST COMMUNITY AFFILIATIONS (CLUBS, SERVICE ORGANIZATIONS, ETC.)
___________________________________________________________________________________________________
PERSONAL REFERENCES (Non family members
):
1. _______________________________
Address______________________________Phone________________________
2. _______________________________
Address______________________________Phone________________________
3. _______________________________
Address______________________________Phone________________________
1 | Page July 2010
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2 | Page July 2010
EMERGENCY CONTACT – NAME __
RELATIONSHIP__________________________HOME PHONE________________ALTERNATE PHONE __
REASON FOR VOLUNTEERING (for example - Experience needed for School, Community Service, Retired)
_________________________________________________________________________________________________________
AREA OF WORK PREFERRED (Hospice, Clerical, General office etc. ____________________________________
If you prefer clerical or general office work, indicate the following: Typing _____
WPM 10 Key______ Strokes
Excel Word PowerPoint Other:
LIST ANY OTHER PROFESSIONAL TRAINING, CERTIFICATIONS OR SPECIAL SKILLS, LICENSES, PUBLICATIONS OR OTHER
RELATED ITEMS:_______________________________________________________________________________
____________________________________________________________________________________________________
IF YOUR VOLUNTEER ACTIVITIES INVOLVE DRIVING, YOU WILL BE REQUIRED TO SUBMIT A DRIVERS LICENSE, DRIVING
ABSTRACT, PROOF OF INSURANCE, OR OTHER PERTINENT INFORMATION.
DO YOU HAVE AN AUTOMOBILE? Yes_____
No_____
CAN YOU SPEAK A LANGUAGE OTHER THAN ENGLISH? Yes___
No____ If yes, what language(s) and how would you rate
your fluency? _________________________________________________________________________________________
Medical clearance, including negative tb (2-step or chest x-ray), must be verified by St. Francis Healthcare
System before a volunteer can report to her/his assigned department.
Please check (√) the time slots below when you will be available to volunteer.
Mon Tues Wed Thurs Fri Sat Sun
Mornings 8 am – 12 pm
Afternoons 12 pm – 4 pm
Evenings 4 pm – 8 pm
Other hours available:
PLEASE COMPLETE ONLY IF YOU ARE INTERESTED IN VOLUNTEERING FOR HOSPICE:
Has anyone close to you passed away? Yes_____
No____ If yes, please explain when and what your
relationship with the individual was: _________________________________________________________
______________________________________________________________________________________
Please write a statement regarding why you wish to work with the dying patients and their families:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3 | Page July 2010
St. Francis Healthcare System of Hawaii
Volunteer Programs Department
Volunteer Acknowledgement of Confidentiality Policy
It is the policy of St. Francis Healthcare System of Hawaii that all volunteers must safeguard information regarding
patients/families and employees. No medical information, including the fact that a person has been treated in the hospital,
and/or hospice may be released except by the patient/families themselves; including volunteers who are patients. All
information is to be kept completely confidential and not discussed with others, including other volunteers. The only
exception is in the event that information is needed for medical treatment or to comply with legal processes or legal
requirements.
This policy also applies to volunteers who gain information about operations, activities and business affairs of the company.
Any such information is to be kept in strictest confidence and is not to be discussed with anyone other than the appropriate
entity staff. Questions about specific instances should be directed to your supervisor.
Volunteers are asked to sign this statement to indicate their understanding of this policy. Any volunteer who violates this
policy is subject to disciplinary action, up to and including termination, and may also be subject to civil and/or criminal
penalties for violations. Violations by others should be reported immediately to your supervisor.
Volunteer Acknowledgement Signature
______________________________
Date____________________
Print Name _________ ______
Volunteer Agreement
I agree to abide by the policies and regulations of St. Francis Healthcare System of Hawaii and to participate in orientation
and training as required. I plan to/have read the Volunteer Programs Handbook that I will receive at the orientation class.
I understand that all volunteer work is undertaken without any expectation of monetary or pecuniary benefit or payment of
any manner of compensation by St. Francis Healthcare System of Hawaii.
I further understand and agree that St. Francis Healthcare System of Hawaii may, at any time, and without notice or reason,
dismiss me or any individual from voluntary service.
Volunteer Acknowledgement Signature_______________________________ Date___________________
4 | Page July 2010
VOLUNTEER NOTICE & AUTHORIZATION
REGARDING CRIMINAL BACKGROUND CHECK
A criminal background check may be done to verify this information. While disclosing a
criminal conviction will not automatically disqualify you from volunteering, omissions
and/or falsifications of information provided may result in termination from the volunteer
program.
Have you been convicted* of a crime within the last 10 years?
Yes No
If yes, please (1) explain when and where, and (2) describe the nature and outcome of
the case.
*Convicted means an adjudication (decision) by a court that the defendant committed a
crime, not including final judgments required to be confidential pursuant to section 571-
84 in the Hawaii Revised Statutes.
Attestation/Declaration Statement
: I hereby certify that the volunteer application,
resume, criminal conviction, and/or information provided by me is true and complete and
without omission to the best of my knowledge. I understand that misrepresentation of
any material facts, including experiences, skills, and qualifications, may exclude me from
consideration for volunteering or may result in my termination if discovered after I am
accepted into the program. I also understand that my volunteering is contingent upon
completing an Immunization Review and reference check.
Signature:
Date: ______________________
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Completed 17 October 2020

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