Which facility are you interested in volunteering at?


Student Volunteer Application

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do you have any physical limitations?


 

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


 

Do you have any family members who work for MSHA?


 

Have you volunteered with MSHA before?


 
 
Availability
Please select the days and times you are available to volunteer

Days:







Times:



Interests and Goals

Briefly explain why you are interested in volunteering and what areas in which you would like to serve.

 

Goal 1:

 

Goal 2:

 

Goal 3:

 

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


 

If so, please list the specific areas you are interested in:

Are you required to volunteer?


 

Have you ever been convicted of a criminal offense?


 
 
NOTE: Please have this person complete the volunteer reference form
 
 
NOTE: Please have this person complete the faculty reference form
 

Agreement

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 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.

I 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 and/or investigation.

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.

v  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 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.

Do you agree to the terms?