Remote Volunteer Application

Personal Information

* First or preferred Name

* Last Name

* Mailing Address

* City

* State

* Zip Code

* Cell Phone

Home Phone (if different)

* E-mail Address

* Date of Birth (mo/day/year)

Social Security Number (we need to perform a background check)

* For what remote role are you applying?

* Please tell us why you are interested in volunteering for BIDMC, and what you hope to accomplish or gain during your time as a volunteer?

In what languages are you proficient?

Optional - What is the highest level of education you have completed?

Current school/institution (if a student)

Expected graduation date (if a student)

Is there anything else you would like us to know (special talents, availability?)

To the best of your knowledge, are you eligible to work within all federal health care programs, state health care programs, and federal procurement or non-procurement programs?

Have you been excluded, suspended, debarred, or otherwise ineligible from working within any federal health care programs, state health care programs, or within federal procurement or non-procurement programs?

Optional - Upload a photo of yourself

PLEASE READ CAREFULLY AND SIGN THE STATEMENT BELOW

I certify that the information given above is true and complete and I understand that misrepresentation and/or withholding of information will result in the rejection of this application or my discharge if discovered after volunteer service begins. I authorize the Medical Center to make inquiries regarding my history and character of prior employers, schools, etc. and hereby release employers, schools or individuals from all liability in responding to inquiries in connection with my application and release the Medical Center from all liability with respect to such inquiries.

I understand that if I am a volunteer, I will be a volunteer "at will" and may terminate my volunteer assignment at any time with or without cause or notice and that the Medical Center also has that right. I also understand no representative of the Medical Center, other than the President, has any authority to enter into any agreement for volunteer service for any specified period of time or to make any agreement contrary to the foregoing and that such agreement must be in writing. As a volunteer, I agree to abide by the Medical Center's policies, rules and procedures and any changes thereto.

I understand that I must provide the Medical Center with updated immunization records that include verification of a Tuberculosis test within the past year. If under 18 years of age, please use the enclosed parental consent form.

I Agree