Volunteer Application Form

VOLUNTEER SERVICES DEPARTMENT
HealthSource Saginaw, Inc.
3340 Hospital Road -- P.O. Box 6280
Saginaw, MI 48608-6280

VOLUNTEER REGISTRATION FORM

THE INFORMATION ON THIS FORM WILL HELP US TO FIND THE MOST SATISFYING AND APPROPRIATE VOLUNTEER SERVICE FOR YOU. YOUR COOPERATION IN COMPLETING THIS FORM IS MOST APPRECIATED.

Name:

Home Address:

City:

State:

Zip:

Home Telephone:

Date of Birth:

Education:

Emergency Contact Name/Relationship:

Phone:

Previous Work Experience:

Are you presently employed?

YesNo If Yes, hours per week:

Your current duties are:

Employer's name and address:

Special skills, interests, training or hobbies:

Time you have available for volunteer work:

Required hours:

Deadline Date:

Hours per week:

Regularly each week: YesNo

Almost any time:

YesNo

REFERENCES: (Excluding family/friends)

1) Name:

Phone:

2) Name:

Phone:

CONFIDENTIALITY STATEMENT

I UNDERSTAND AND AGREE THAT IN THE PERFORMANCE OF MY DUTIES AS AN AUXILIAN AND/OR VOLUNTEER OF HEALTHSOURCE SAGINAW, INC., I MUST HOLD PATIENT/RESIDENT/CLIENT INFORMATION IN CONFIDENCE. I UNDERSTAND THAT INTENTIONAL OR VOLUNTARY VIOLATION OF PATIENT/RESIDENT/CLIENT CONFIDENTIALITY MAY BE CAUSE FOR IMMEDIATE TERMINATION OF MY SERVICES TO HEALTHSOURCE SAGINAW, INC. AND COULD RESULT IN POSSIBLE FINES AND/OR IMPRISONMENT.

I Agree