BIDMC Volunteer Application

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information

* First (or preferred) Name

* Last Name

* Home Address

* City

* State

* Zip Code

* Cell Phone

Home Phone

* E-mail Address

* DOB

Are you at least 15 years of age?

If you are 18 years of age or older please select 'Adult'. If you are less than 18 years old please select 'Youth'.

Emergency Information

* Name of Emergency Contact

* Relationship

* Phone

Volunteer Experience (if applicable)

Name of Volunteer Organization

Types of Duties Performed

Dates that you volunteered with this organization:

Name of Volunteer Organization

Types of Duties Performed

Dates that you volunteered with this organization:

Employment Information (if currently employed)

Current Employer

Current Position/Title

School or university information (if currently a student)

School or University (if currently a student)

Expected graduation date

Major (if applicable)

Highest level of education completed

Volunteer Interests:
Volunteer assignments are based on the needs of the medical center and on the candidate's interests and availability. To give us a sense of your interests, please check all that apply:
Clinical - You would like to volunteer in a role that would involve patient interation.
Administrative - You would like to volunteer in a role that would involve administrative duties, such as office work or data entry, that would have minimal patient interaction.
Future Healthcare Worker - You are interested in a healthcare career (Nursing, Pre-Med, PA, pharmacy, etc.) and seeking experience.
Short Term: You are interested in taking part in short-term projects or opportunities.
Remote: You prefer to volunteer remotely.

Please check all interests that apply:

Is there anything else you would like us to know about your interests or preferences?

Please select times available

How long would you be able to volunteer at BIDMC? Please note that, except for certain assignments, we require a minimum of 40 hours, and prefer commitments of 6 months or more.

Comment:

* Why do you want to volunteer at BIDMC?

Do you have any particular skills that would be helpful in a volunteer assignment?

What languages do you speak?

Please provide contact information for two references. References should not be members of your family, or close friends. We will email a link to a reference survey to the references that you provide.

* Reference #1 Name:

* Reference email address:

* Reference phone number:

Reference's relationship to you:

Company, organization, or educational institution that reference is affiliated with (if applicable):

* Reference #2 name:

* Reference #2 email:

* Reference #2 phone:

Reference's relationship to you:

Company, organization, or educational institution that reference is affiliated with (if applicable):

Who referred you to BIDMC?

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?

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

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