Please list two personal, educational or job references whom we may contact.
- -
- -
Yes
No
Have you even been convicted of a c
rime other than a minor traffic violation? Yes
No
Have you ever paid for a worthless check in the office of a Clerk of Court to resolve any violation of the law?
Have you ever paid a fine or restitution in the office of a Clerk of Court to resolve any violation of the law?
Yes
No
If yes to any of the previous three questions above, please explain. (Yes does not automatically disqualify you
from volunteering.)
Pl
ease Read the Following Statements Carefully:
In s
ubmitting and signing this application, I understand that my application will be reviewed by the Director of Volunteer
Services. If I am selected for an interview, I will be notified by phone.
Commitment
• I must provide a minimum of 3 ½ - 4 hours of service once per week, for at least three months.
• If I am a college student, I must commit to a minimum of at least one semester and complete 40 hours of volunteer
service.
• It is required that I complete the three-month commitment for a school or job reference.
• It is my responsibility to get the necessary transportation to and from volunteering.
• I understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties
outside of my service guidelines.
Training/Health
• A volunteer orientation and health screen is required within two weeks of my volunteer placement.
• All current required immunizations will be given to me unless documented proof is submitted to Employee Health.
• I must undergo an update of the TB skin test and in-service review annually.
• If there is cause for concern, I will consent and agree to voluntarily provide body fluid (blood and/or urine) samples
for drug and/or alcohol screening in accordance with Medical Center policy.
• The results of such screenings may be released to the Medical Center, and the results may be used to make decisions
concerning my involvement with the Medical Center.
• I will be required to attend two on-the-job training sessions. Management will follow-up with me within a reasonable
amount of time to ensure that the placement is satisfactory.
Acknowledgement of Hospital Criminal Record Checks
• Criminal record checks will be performed on every applicant volunteering at Wake Forest Baptist Health.
• If the information that I have furnished on this form is found to be false, I could be disqualified/dismissed.
I hereby apply to become a Volunteer at Wake Forest Baptist Health, to abide by my commitment, to keep all patients’
information strictly confidential, and comply with all rules and regulations.
By checking this box, I verify that the statements given on this application are true and accurate to the best of my
knowledge.
