Mountain States Health Alliance | College Volunteer Application

Student Volunteer Application

Preferred Facility (Check all that apply)

Blue Ridge Medical Management
Franklin Woods Community Hospital
Indian Path Medical Center
Johnson City Medical Center
Johnson County Community Hospital
Johnston Memorial Hospital
Niswonger Children's Hospital
Quillen Rehab Hospital
Russell County Medical Center
Smyth County Community Hospital
Sycamore Shoals Hospital
Hospice

Full Name: *

Date: *

Age: *

Date of Birth: *

SSN (required if 18 or older for background check): *

Current School: *

Major: *

Classification: *

Home Street Address: *

City: *

State: *

Zip: *

Home Phone: *

Cell Phone:

Email Address: *

Name of Parent/Guardian/Spouse:

Parent/Guardian/Spouse Daytime Phone: *

Parent/Guardian/Spouse Evening Phone: *

Emergency Contact Name: *

Emergency Contact Phone: *

Do you have any physical limitations?

Yes
No

Are you under any treatment that would limit your ability to perform certain activities?

Yes
No

Special Skills (Ex: Photography):

Do you have any family members who work for MSHA?

Yes
No

If yes, where do they work?

Have you volunteered with MSHA before?

Yes
No

If yes, when?

How did you hear about volunteering at MSHA? *

Availability

Please select the days and times you are available to volunteer

Days:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Times:

Mornings
Afternoons
Evenings

Interests and Goals

Briefly explain why you are interested in volunteering (Please note if you are compelting Observation/Job Shadowing Requirements):

List 3 personal goals you want to achieve as a College Volunteer

Goal 1:

Goal 2:

Goal 3:

Are there any specific areas that you would like to volunteer in?

Yes
No

Are you required to volunteer?

Yes
No

If so, by whom?

Have you ever been convicted of a criminal offense?

Yes
No

Name of character reference: (non-family) *

NOTE: Please have this person complete the volunteer reference form

Phone of character reference: *

Name of faculty reference: *

NOTE: Please have this person complete the faculty reference form

Phone of faculty reference: *

Please read the volunteer agreement below

I understand and agree that at no time will any information regarding patients of Mountain States Health Alliance be revealed to anyone other than those authorized to receive it. I understand that the giving of the information concerning a patient to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.

I understand that false statements made as a part of this enrollment may be considered sufficient cause for dismissal

I authorized and consent for all named references and educational institutions to release any personal and/or professional information about me to the MSHA volunteer Office. I understand I have consented to these things as described herein, and in doing so, I further release, hold harmless, and indemnify Mountain States Health alliance, the Volunteer office, and any and all MSHA employees, offices, directors, and/or authorized agents, as well as those individuals or entities supplying such information about me, and/or conducting such search and/or investigation, from any liability, claims and/or causes of action as a result of any such inquiry, search and/or investigation.

I understand that if I am accepted as a volunteer:

I will abide by Mountain States Health Alliance's general policy concerning patient confidentiality
I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a result of my services, and MSHA is not legally liable for any worker's compensation coverage or other similar benefits as a result of my services.
I will observe all hospital regulations
I will endeavor to be prompt and regular in my services and I will perform my assigned volunteer duties to the best of my ability
I will commit to volunteer when I am scheduled
I will adhere to the MSHA Volunteer Dress Code
Photos taken while participating as a MSHA volunteer or at special functions may be used for promotional reasons.

Do you agree to the terms?

Yes
No

Clicking the send button is your electronic signature stating that the information you have submitted is correct and that you agree to all of the terms and conditions of this application.