Student Volunteer Application
Please select the days and times you are available to volunteer
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
NOTE: Please have this person complete the volunteer reference form
NOTE: Please have this person complete the faculty reference form
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.
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.