BIDMC Volunteer Application

Name of Volunteer Organization

Types of Duties Performed

Year(s) that you volunteered with this organization:

Name of Volunteer Organization

Types of Duties Performed

Year(s) 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

Expected graduation date

Major, type of degree, or program of study (if applicable)

Highest level of education completed

No High School Some High School High School Some College Professional/Trade School Two year Degree Four year Degree Graduate Degree Doctorate

* Why do you want to volunteer at BIDMC?

Availablity & Commitment

* 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 strongly prefer commitments of 6 months or more.

Please select times that you would be available to volunteer. Typically, people volunteer for at least one 3 - 4 hour shift per week, though some roles differ.

Mornings Afternoons Evenings Mondays Tuesdays Wednesdays Thursdays Fridays Weekends

Is there anything else you would like us to know about your availability? (Example: 'will be away during summer break.')

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

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

What languages do you speak?

Afrikaans Akan Aklanon Albanian Algerian Amharic Arabic Arawakan Armenian ASL Avestan Ayapathu Aymara Azeri Bamwe Bantu Basa Basque Belarusan Bemba Bengali Berber Bicol Bisaya Bobangi Bosnian Brahui Breton Bukusu Bulgarian Burmese Butuanon Byelorussian Cambodian Cantonese Catalan Cayuga Cebuano Ch'ol Chaldean Chamorro Chechen Chewa Chinese Chinook Chorti Coptic Cree Creole Croatian Czech Danish Dari Demonh'ka Dothraki Dutch Ebu Eggon Egyptian Emakua English Eskimo Estonian Etruscan Fang Faroese Farsi Filipino Finnish Flemish Frankish French Fujanese Fuzhounese Gaelic Gaelic (Irish) Gaelic (Scottish) Gaelic (Welsh) Galician Gamilaraay Ganda Gaulish Gbari Georgian German Gevove Gilbertese Gothic Greek Guarani Gujarati Guyanese Creole patois Haida Haitian Hakka Halaka Hausa Hawaiian Hebrew Hiligaynon Hindi Hmong Hungarian Icelandic Igbo Ilocano Ilonggo Indonesian Ingush Inupiat Italian Japanese Jita Kachi Kakwa Kalanga Kannada Kapampangan Karelian Kashmiri Katcha Kazakh Kerewe Khmer Khowar Kiga Klallam Klingon Kongo Konkani Korean Koyo Kurdish Lakhota Latin Latvian Lebanese Lingala Lithuanian Lozi Luganda Luwian Lycian Lydian Mabwe Macedonian Malay Malayalam Maliseet Maltese Mandarin Mandinka Manx Maori Mapudungun Marathi Masaba Mawu Mayan Mayangna Miami Minbari Miskitu Mixtec Mohawk Mongolian Mpongwe Nahuatl Nande Nauruan Navajo Ndebele Nepali Norwegian Nyamwezi Occitan Ojibwe Olkola Olutec Onondaga Oriya Oykangand Pahlavi Pakahn Pali Papiamento Pashto Pende Persian Phoenician Phrygian Pidgin Piraha Polish Popoluca Portuguese Potawatomi Prussian Punjabi Quechua Rasta Rejang Romanian Romany Rotuman Russian Saanich Sanskrit Seneca Serbian Seri Shanghainese Shi Shona Signing Exact English Sindhi Sinhala Slovak Slovene Sogdian Somali Sorbian Spanish Sranan Sudovian Sumerian Swabian Swahili Swedish Tagalog Taishanese Taiwanese Tajik Tamazight Tamil Tarahumara Tarok Tatar Telugu Teochew Thai Thracian Tibetan Tlingit Tocharian Tongan Treu Chau Turkish Turkmen Twi Ukrainian Ulwa Umbrian Urdu Uyghur Uzbek Venda Veps Vietnamese Visayan Votic Warlpiri Welsh Wolof Xhosa Yaka Yao Yemba Yiddish Yoruba Yupik Zoque Zulu

References: 

Please provide contact information for two references. References should not be members of your family, or close friends. If we have openings that may fit your interests and availability, 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:

Parent Employer Pastor/religious leader Law enforcement Relative Friend Teacher Professional Personal Other

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:

Parent Employer Pastor/religious leader Law enforcement Relative Friend Teacher Professional Personal Other

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?

Yes No

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?

Yes No

PLEASE READ CAREFULLY AND CHECK "I AGREE" 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