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):
If so, please list the specific areas you are interested in:
NOTE: Please have this person complete the volunteer reference form
NOTE: Please have this person complete the faculty reference form
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.
agree to any necessary health screening required by the hospital and
understand my volunteer assignment is contingent upon successful
completion of this screening. I UNDERSTAND I MUST HAVE A TB SKIN TEST ND FLU VACCINATION BEFORE I CAN BEGIN VOLUNTEERING. The hospital will perform these at no charge to the volunteer.
I understand that false statements made as a part of this enrollment may be considered sufficient cause for dismissal.
authorize and consent for all named references and educational
institutions or previous places of employment to release any personal
and/or professional information about me to the MSHA Volunteer Office. I
also consent to a law enforcement record search and/or any other
background investigation of me if chosen by the 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, officers, 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
I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER:
v I will abide by Mountain States Health Alliance’s general policy concerning patient confidentiality.
v My assignment is on a probationary basis for a period of 60 days.
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 hereunder.
v Photos taken while participating as a MSHA volunteer or at special functions may be used for promotional reasons.
v I will observe all hospital regulations.
Submitting this form is your electronic signature and your acceptance of the Agreement above.