join us volunteer application form Step 1 of 333%Personal InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code BirthdateMonth / Day / YearPhoneEmail* How do you prefer to be contacted? Phone Email EitherEmergency ContactEmergency Contact Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Work PhoneEducationName of High SchoolYears AttendedName of College / Professional SchoolYears AttendedCourse of StudyDid You Graduate? Yes NoWork ExperienceList your previous work experienceName of EmployerPosition HeldStarting DateEnding DateAdd work experienceRemove work experienceUse the "Add work experience" button to add more fields.Special Skills / TrainingHave you ever worked for NTMC?* Yes NoIf yes, when did you work for NTMC?DepartmentCivic Clubs / Volunteer Experience (click the + icon to add more rows)Hobbies (click the + icon to add more rows)Volunteer PreferencesDay of week desired Sunday Monday Tuesday Wednesday Thursday Friday SaturdayShift preferred Early Morning (6am - 9am) Morning (9 - 12) Afternoon (12 - 3) Evening (3 - 5:30/6pm)Type of volunteer work preferred (click the + icon to add more rows)Personal ReferencesNamePhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Add referenceRemove referenceIf referred by a current NTMC volunteer or you know present volunteers, please list.Why would you like to be an auxiliary volunteer at NTMC?If accepted as a hospital volunteer, I understand that*I authorize NTMC to investigate all facts contained in my application for volunteer service with said hospital, and authorize the release of any and all information by my present and past employers or volunteer agencies, wherever located, which may be required for a reference check. I further authorize all of my previous employers and current employer and/or volunteer agencies that I served to give any and all information concerning my service and any other pertinent information which said employers or volunteer agencies may have, personal or otherwise, and I release all parties from all liabilities for any damages which may result from the furnishing of said information. In accepting the opportunity for volunteer services at NTMC, I pledge to give dependable, punctual and conscientious service. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient. My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian, religious or charitable reasons. I shall submit to examinations, which may include chest x-rays, skin tests, appropriate laboratory tests and/or immunizations that may be necessary as part of my volunteer service. I hereby authorize my doctor(s) making tests or x-ray films to report the results to the hospital. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my volunteer work professional in quality. I shall make the best effort to fulfill my commitment to the hospital by completing all assignments that I accept. I shall at all times uphold the philosophy and standards of the hospital. I understand that my first 3 months of volunteering will be a probationary period with a review. I also understand that at any time in my service as a volunteer in the future, the volunteer services department reserves the right to terminate my volunteer status as a result of (a) failure to comply with hospital policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance, or (d) any other circumstances which, in the judgment of the department director and the NTMC administration, would make my continued service as a volunteer contrary to the best interests of the hospital. I agree to the above.NameThis field is for validation purposes and should be left unchanged.
