Volunteer Application

• Hospital Name:* Select a hospital Allegheny General Hospital Allegheny General Hospital Suburban Campus Allegheny Valley Hospital Canonsburg Hospital Forbes Hospice Forbes Hospital Jefferson Hospital Saint Vincent Hospital West Penn Hospital Wexford Health + Wellness

• First Name:*
• Last Name:*
• Gender:* Male   Female
• Address (street, apt #):*
• City:*
• State:* Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip:*
• Home Phone:*
• Cell Phone:
• E-mail Address:*
• Were you previously a volunteer within the Allegheny Health Network?* Yes   No

• Why did you select Allegheny Health Network for volunteer service?*
• Education (Please list schools attended, degrees and diplomas earned)*
• Work Experience (Please list Employment and Dates)
• Volunteer Experience
• How would you most like to help us?* Help Patients
  Visitor/Family Support
  Gift Shop
  Fundraising
  Clerical Support
  Other:
• Skills, Hobbies, or Interests*
• Special Needs:
• Days Available:* Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
  Sunday
  
• Hours Available:* From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  
• Are you related to any employee or staff member of Allegheny Health Network?* Yes   No
  

• Have you ever been employed by Allegheny Health Network?* Yes   No
  

• Are you required to perform court-ordered community service?* Yes   No
  
• Have you ever been convicted of a felony?* Yes   No
  

• Name:*
• Relationship:*
• Phone/Address*

• Name:*
• Relationship:*
• Phone/Address*

• Name:*
• Relationship:*
• Phone/Address*

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief and have been given voluntarily. I understand that Allegheny Health Network requires certain information both personal and professional from me to evaluate my qualifications and consider me for volunteer services. I understand that in consideration of my application, a background investigation may be conducted. I hereby grant Allegheny Health Network permission to verify such answers and investigate all references, and conduct such further investigation as is necessary, including, but not limited to, the performance of medical examinations, drug screening, reference verification, military service verification, and criminal background checks. I understand that any false statements or incomplete information on this application may be considered sufficient cause for rejection of this application or for dismissal if such information is discovered subsequent to my volunteer work. I authorize any past and present employers, personal references, and other organizations, to answer all questions asked concerning my previous employment and/or volunteer record, ability, character, educational background, military service, or criminal history. I hereby release all employers, persons or organizations, from any liability whatsoever for providing this information. I understand that I may be asked to discontinue my volunteer services at any time for any reason. I understand that Allegheny Health Network will not be responsible for any personal injury or property loss that may occur to me while performing volunteer services.

I understand that I will not receive any monetary compensation from Allegheny Health Network, individual employees or anyone else for serving as a volunteer. I hereby agree to abide by all policies and procedures of Allegheny Health Network. I will treat information regarding patients and employees in strict confidence.

By submitting this application I agree with the Applicant’s Certification.