BIDMC Volunteer Application

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information

* First (or preferred) Name

* Last Name

Preferred Pronouns:

* Profile photo

* Home Address

* City

* State

* Zip Code

* Cell Phone

Home Phone

* E-mail Address

* Date of Birth

* Photo ID (Can be a Student ID, State ID, License or Passport)

If you are 18 years of age or older please select 'Adult'. If you are less than 18 years old please select 'Youth'. (Please note: people under 15 years old will not be selected to volunteer)

Emergency Information

* Name of Emergency Contact

* Relationship

* Emergency contact's e-mail

* Emergency contact's phone

Volunteer Experience (most recent and if applicable)

Name of Volunteer Organization

Types of Duties Performed

Year(s) that you volunteered with this organization:

Employment Information (current or most recent employment and if applicable)

Current Employer

Current Position/Title

Education (If currently a stuent or most recent)

Current or most recent school or university

Graduation year or expected graduation year

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

Highest level of education completed

Interests

* Check the OPPORTUNITIES page above ^, please list 3 roles you are most interested in. If all 3 roles you are interested in are not available you will be waitlisted.

* Why do you want to volunteer at Beth Israel Deaconess Medical Center?

Availability & Commitment

How long would you be able to volunteer at BIDMC? Please note that there is a minimum number of hours and/or months associated with each position.For onsite roles, we prefer at least a 6 month commitment. Most roles have an expectation of once per week for 3-4 hours.

Please select days of the week and times of day that you would be available for a 3-4 hour shift. Select all that apply so that we may determine if there is role with an open shift that matches your availability.

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 skills, experience, or preferences?

What is your unisex T-Shirt size?

What languages do you speak?

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:

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? (name, email)

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 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