Auxiliary

VOLUNTEER APPLICATION

(applicants must be 18 years of age or older)

Bear Lake Memorial Hospital exists to perpetuate and foster access to optimum quality health care to the residents and visitors of the Bear Lake area. Our volunteers play a key role in providing quality services throughout the hospital campus and for our community. Our volunteers must uphold the Hospital’s values of integrity, compassion, a giving attitude, striving for excellence, and a willingness to learn.

Full Name *

Phone

Mailing Address :

City

Email *

Cell Phone

Date of birth

Why do you want to volunteer at Bear Lake Memorial Hospital?

Have you ever volunteered before?
YesNo

If so, where and when?

What type of volunteer service are you interested in? (check all that apply)
Patient assistanceElder careClericalGift ShopThrift storeEvents and community servicesSpiritual SupportQuiltingMusic TherapyComputer workArea of special interest

Please check the day(s) you would be available to volunteer:
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Please check the times you would be available to volunteer:
Mornings Approx. 8am-12:30pmAfternoons Approx. 12:30-5pmEvenings Approx. 4-8pm

Can you perform the functions of the job(s) you are interested in either with or without reasonable accommodation?

Do you have a friend who is currently a Bear Lake Memorial Hospital Volunteer?
YesNo

Of so, Name?

REFERENCES: Personal and Professional

Please list two references: Do not list a parent or relative as a reference.

1st Reference:

Job Title:

Phone:

2nd Reference:

Job Title:

Phone:

Do you have current or previous work experience?
YesNo

If yes, where?

Duties performed

Please check the skills you can share with us:
BookkeepingCustomer serviceRetail operationsClerical dutiesComputersLeadershipClinical/ healthcareHousekeepingMaintenance and repair workSewing/ quiltingEducator/ Trainer

In the event of illness, injury or emergency, contact.

Name

Phone

Relationship

I am interested in joining the Bear Lake Memorial Hospital Auxiliary. Please forward my application to the BLHM Auxiliary membership committee for acceptance and approval.

Applicant’s Agreement, Statement & Authorization(s)

As a Volunteer, you are considered a member of our Bear Lake Memorial Hospital family, and as such you have certain responsibilities to the Hospital and its patients: to observe the same code of ethics as those on the professional staff, to adhere to the Hospital policies and procedures, and to uphold patient confidentiality.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any volunteer relationship with Bear Lake Memorial Hospital is of an “at will” nature, which means that the Volunteer may resign at any time and Bear Lake Memorial Hospital may discharge the Volunteer at any time with or without cause. It is further understood that this “at will” relationship may not be changed by any written document or by conduct unless change is specifically acknowledged in writing by an authorized executive of the organization.

Volunteer Certification and Agreement (Please read the following before signing)

By my signature below, I further understand that:

I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am selected as a Volunteer, is sufficient cause for dismissal regardless of when the misrepresentation or omission of fact is discovered.

I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, type tests, etc.) of information contained in this application. I authorize any and all persons, companies, or agencies to release to Bear Lake Memorial Hospital any and all information they may have, which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to Bear Lake Memorial Hospital.

I agree that if I am selected by Bear Lake Memorial Hospital as a Volunteer, I will review the information contained in the Volunteer Handbook and follow the practices described therein.

I understand that my working as a Volunteer for Bear Lake Memorial Hospital is contingent upon the following: Satisfactorily completing a criminal background check along with fingerprinting, and obtaining two satisfactory reference checks.

Before beginning an Active Volunteer Assignment, I will be required to attend an orientation, take an annual tuberculosis test (at no cost to the Volunteer) AND clear all background checks.

I acknowledge that I have read the certification and agreement, and agree to abide by its terms. I authorize Bear Lake Memorial Hospital to conduct a criminal background check along with fingerprinting.

Volunteer Applicant’s Signature

Date

Incomplete applications will not be accepted.

Volunteers accepted for placement, will be located in areas which will be of interest and value to them.

Acceptance of completed applications does not constitute acceptance into the Volunteer Program.

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