name

South Davis Community Hospital

Volunteer Application

Legal Name (Last, First, Middle):
Current Address (Street, City, State, Zip):
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email Address:
Birth Date (mm/dd/yyyy):
How did you learn about us?
Do you have a preference for a particular service area?  If so, please state:
Are you currently employed?
Yes  No 
 
Check days and hours you're available for volunteering:
Monday AM 
Monday PM 
Tuesday AM 
Tuesday PM 
Wednesday AM 
Wednesday PM 
Thursday AM 
Thursday PM 
Friday AM 
Friday PM 
Saturday AM 
Saturday PM 
Sunday AM 
Sunday PM 
Is there a medical condition(s)that you are currently being treated for or taking medications that we should be aware of?
Yes  No 
 
If yes, please explain:
To help provide you with a satisfying volunteer experience, please tell us a little bit about yourself: 
Hobbies:
Special skills or talents:
Do you have prior volunteer experience?
Yes  No 
 

Where?

Personal References:
Name:
Phone:
Name:
Phone:

I will respect the privacy of South Davis Community Hospital patients.  I will not discuss a patient's presence, identity, diagnosis or treatment with anyone either inside or outside the hospital.  I will keep all information that I come in contact with whether by sight or by hearing strictly confidential.

All hospital employees and volunteers are bound by a professional code of ethics.  This if for your protection as well as that of the patient.

I understand that I will automatially be dismissed from my volunteer duties if I do not respect my responsibility for maintaining confidentiality.

I Have Read and Understand the Confidentiality Agreement

Date:
Signature:
Parental Consent For Applicants Under 18 Years Old:
Date:
Signature:
Emergency Contact:

Name:

Phone Number(s):
Relationship:

South Davis Community Hospital

Background Check Waiver

I hereby state that I have not been convicted of or am awaiting trail for a felony, a misdemeanor charge or had a substaintiated finding of abuse.
Yes  No 
 
I have been convicted or am awaiting trial for a felony, a misdemeanor charge or had a substantiated finding of abuse.
Yes  No 
 
If you answered "yes" to the above question, please write an explanation of the charges.
I understand South Davis Coummunity Hospital will conduct an annual check of my criminal history to ascertain any and all information which may be pertinent to my volunteer duties.  I do hereby release all persons, organizations (including by not limited to SDCH), or government agencies from any damages resulting from furnishing such information.
Signuture of Authorizing Individual:
Date:
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