Volunteer Application

Dear Prospective Volunteer,

Thank you for applying for a volunteer position with Beth Israel Deaconess Medical Center.

Sincerely,

The Volunteer Services Department

New User Details

User ID

User ID (verify)

Password

Password (verify)

We ask that you submit 2 letters of reference along with your application. You will not be able submit this application without your 2 letters of reference. These letters of reference should be from persons who have known you for several years, (eg: Rabbi, Priest, Minister, Physician, Teacher, Counselor or Employer). If you do not have these with you now, please bookmark this webpage. We look forward to receiving your application along with your 2 references.

Personal Information

* First Name

* Last Name

* Home Address

* City

* State

* Zip Code

Home Phone

* Cell Phone

* E-mail Address

Are you at least 14 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

Home phone

* Mobile Phone

Employment Information

Current Employer

Current Position/Title

Employer's address

Volunteer Experience and Education

Name of Volunteer Organization

Types of Duties Performed

Date Started

Date Ended

Name of Volunteer Organization

Types of Duties Performed

Date Started

Date Ended

If you are currently a student, please complete this section.

Major

School or University

Interest and Availability

As a volunteer, we ask that you are able to commit to one four-hour shift each week, with some roles available evenings and weekends. Volunteer placement depends upon the needs of the Medical Center.

Volunteer Opportunities:

Clinical - Volunteering in a role that would allow patient interation

Clerical - Volunteering in programs that involve clerical duties with minimal patient interaction

Future Healthcare Worker - Volunteers must be interested in a career in one of these fields (Nursing, Pre-Med, PA, etc.) and seeking experience in a clinical environment

Job preferences (as checklist)

Please select times available

Can you commit to giving BIDMC a 1 day, 4 hour shift per week for a minimum of six months?

* Why do you want to volunteer at BIDMC?

Who referred you to BIDMC?

What languages do you speak?

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

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.

* Letter #1

* Letter #2

* I Agree

Please sign your name by holding your right mouse button and moving it around to create your e-signature

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E-Signature