Volunteer Services
Sutter Roseville Medical Center

Please complete this application if you are interested in a volunteer placement at Sutter Roseville Medical Center (SRMC). Note: you must be able to make at least a one year commitment.

Profile

Last Name:

First Name:

Middle Initial:

Date of Birth:

Gender (optional):

Male Female

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email
We do not share your email with anyone else; however, it is the primary way we inform you of what’s going on.

Email address:

Experience

Have you ever been employed at Sutter Health: Yes No

Are you currently employed or attending school: Yes No

If Yes, please explain:

Tell us about your previous work experience:

Volunteer Experience
Have you had volunteer experience: Yes No

If yes, tell us about your previous volunteer experience

Please provide the names of any SRMC Auxiliary members and/or names of individuals, who would be willing to give a character reference for you.

Name:	Phone:	Aux. Member? Yes No	Years Known:
Name:	Phone:	Aux. Member? Yes No	Years Known:

Availability and Interest
Please tell us in a few sentences why you would like to become a volunteer at SRMC

Please check the days and hours you are available for a volunteer assignment

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning	Morning	Morning	Morning>	Morning	Morning	Morning
Afternoon	Afternoon	Afternoon	Afternoon	Afternoon	Afternoon	Afternoon
Evening	Evening	Evening	Evening	Evening	Evening	Evening

Please review the enclosed “Auxiliary Services” and select below the areas you are interested in

Admitting/Information Desk	Emergency Department	Cancer Registry	Charts
Fund Raising Sales	Comprehensive Cancer Center Clinic	Gift Shop	Inpatient Surgery Recovery
Labor and Delivery	Navigator	NICU	Nursery/Postpartum
Outpatient Recovery	Pediatrics	Physical Rehabilitation	STARS
Surgery Information

Do you have any physical or medical conditions that may limit your ability to perform the duties of a volunteer: Yes No

If yes, what accommodations do you require?

What do you consider your strength as a volunteer?

What would present the toughest challenge to you as a volunteer at SRMC?

Do you enjoy taking a leadership role, or do you prefer to assist others?

How would you handle the stress and emotions that come with working with patients/family members who are dealing with life threatening illnesses?

Some volunteer jobs require volunteers to work independently without direct supervision. Do you prefer to have a supervisor readily available or are you comfortable working alone. Please explain

Have you ever been convicted of a crime (other than a traffic infraction)? Yes No
If yes, indicate the nature and date of the occurrence:

Senior Auxiliary Applications Junior Auxiliary Applications

Confidentiality
Please read and initial at the bottom indicating that you have read and understand the confidentiality requirements at SRMC.

I understand and agree that in the performance of my duties as a volunteer at SRMC, I must hold patient information in confidence. Hospital volunteers have an ethical responsibility to protect patient privacy. Information regarding patients must not be released, disclosed, or discussed either inside or outside the hospital.

There are laws, both state and federal, safeguarding patient records and penalties for the release of confidential information without patient authorization. I understand all may result in action including possible termination, fine, or imprisonment.

As a volunteer, I will consider all confidential information that I hear about patients, families, and hospital personnel as private.

I agree

Background Check and Personal Statement
I certify that the information provided in this application is true and complete. I understand any false information, misrepresentation, or concealment of fact is sufficient grounds for immediate discharge by SRMC.

I understand and agree that all information furnished in this application may be verified by SRMC. I hereby authorize all individuals and organizations named or referred to in this application, and any records repository, or law enforcement organization, to give SRMC all information relative to my employment, work habits, character, credit history, and any criminal records. I hereby release such individuals, organizations, and SRMC from any and all liability for issuing, receiving, and using any such information. I agree that, if accepted, I will abide by the philosophy and all policies and procedures established by SRMC. I further understand that either the hospital or I can terminate my role as a volunteer at any time for any reason.

I agree

Placement
Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, or sex.

The volunteer service is not obligated to provide a placement, nor are you obligated to accept the position offered.

I agree

Volunteer ServicesSutter Roseville Medical Center

Volunteer Services
Sutter Roseville Medical Center