Tanner Health System
Volunteer Services Application

Tanner Health System is an equal opportunity facility and does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, veteran status or any other status protected under local, state, or federal laws.
* Represents Required Fields
Last Name: First Name: Middle Name:
Social Security #:
Birth Date:
Address: City: State: Zip Code:
So we may contact you promptly, please list your phone number(s):
Home: 
Cell:
Work:
Email Address:
Volunteer opportunities vary. Please select the most appropriate category/s.
Driver's License #:  Do you have any health related limitations?
Contact in case of Emergency:
Name: Phone #:
Relationship:
Have you ever been convicted of a crime other than a traffic violation?
Have you ever been fired or asked to resign from a volunteer position?

Education: (select grade completed)

High School: College: Graduate School:
If you are currently a student, where are you enrolled, what year you are in and field of study:
Please list current or past membership in civic, professional or other organizations:
Any previous volunteer work at Tanner Health System?
Area(s) of Interest:

Availability:

Can you make a six month commitment to volunteer at THS?
Do you speak a foreign language?

Volunteer Experience: (Please list your volunteer experience with the most current first)

Organization Name and Address: Phone #:
Supervisor Name:
Dates volunteered (indicate months and years)
From: To:
Please describe volunteer duties:
Reason for leaving:
May we contact for a reference?
Organization Name and Address: Phone #:
Supervisor Name:
Dates volunteered (indicate months and years)
From: To:
Please describe volunteer duties:
Reason for leaving:
May we contact for a reference?

References: (Please list two persons who are not related to you, that may provide a reference)

Name
Address
Phone
Relationship or Occupation
Years Known
Location:

Applicant Acknowledgement and Authorization

I hereby certify that all of the information provided by me in this application (or any accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts will be cause for denial or immediate cessation of volunteer placement regardless of the timing or circumstances of discovery.

I agree to abide by the policies and procedures of THS and the Volunteer Services Department at all times and to support the organization’s commitment to operate in compliance with all applicable laws. I understand that as a Volunteer I may not accept payment for my services and that I will incur the cost of uniforms and transportation and dues.

I understand that submission of an application does not guarantee volunteer placement. I further understand that, should a volunteer position be extended to me that it is at will, and may be terminated with or without cause or notice at any time, at the option of the organization or myself. I understand that serving as a volunteer in no way guarantees any future employment by Tanner Health System. If I take a leave of absence, I understand that my position might no longer be available, and it might be necessary to go through orientation again if the absence is of 6 months duration or longer.

I understand that as a volunteer I have a responsibility to fulfill my duties so that Tanner Health System and my fellow volunteers can depend on me to be there as scheduled and needed. I understand when I don’t do my part that it puts an unfair strain on the other volunteers. I understand that if I am gone, I will need to exhaust every resource to find a substitute. Since the hospital is a year round resource for the area, I understand I have a responsibility to serve all year long. When I do go on vacation, I will work with the staffing person to ensure that my duties are covered. One of the privileges of volunteering is that I have a chance to make a difference in my community. I understand that my community and this hospital will depend on me to fulfill my obligations.

I understand that all information concerning a patient is strictly confidential. Volunteers, as well as hospital employees, have an obligation to refrain from discussing any information to a patient’s illness or treatment except as related to performance of a volunteer assignment.