Name:______

SurnameFirstMiddle

Address:______School:______

Number Street City Postal Code

Phone: ______Date of Birth: ______Year/ Month/ Day

Email Address (If applicable) ______

Emergency Contact#: ______Phone:______

Other than Parent- Name & Relationship to Student

Name of Parent or Guardian: ______Business #______

Day you would like to Volunteer:

Monday Tuesday Wednesday Thursday Friday

Saturday – breakfast ___lunch ___dinner ___

Sunday - breakfast ___lunch ___dinner ___

Your Reason for Volunteering:______

Special interest, hobbies, training:______

______

TO BE COMPLETED BY PARENT OR GUARDIAN:

______, has permission to serve as a volunteer at the hospital, to receive any necessary T.B. testing and to assume the responsibilities of the Student Volunteer Program.

______

Signature Home Phone Business Phone

Relationship to applicant______

Has applicant any limitation which would govern the kind of work he/she is capable of performing?

______

Please clip and keep for reference

Note to all Parents and Students:

The Student Volunteer Program operates based on need at each site and each department. There are various hours and times available to the students. Students work one shift per week and sign in and out for each shift. Students should report to the appropriate site 10 minutes prior to their shift and be at their designated area by their scheduled time in proper uniform, dress cotton pants blue or black, shorts just above the knee are preferred(no ripped jeans, short-shorts, or short skirts). The uniform should be clean and neat, running shoes should be worn at all times – no flip flops, UGGS, Ballet slippers etc.

Credit for volunteer hours will be given once the 50 hour commitment is reached and uniform is returned.

Students must purchase a Volunteer Uniform through the Bluewater Health Foundation for $25.00.

It is mandatory that the student attend the orientation, complete the required health clearance, sign a confidentiality form and have the reference check portion of the application completed.

Should you have any questions, please call me and I would be glad to answer them for you.

Lisa Hendra-Pavey

Manager, Volunteer Resources and Student Affairs

464-4400 Ext. #5406

Please print

Last Name: ______First Name: ______

Department: ______Extension: ______

Position: ______Supervisor: ______

I acknowledge that I have read and understood the Bluewater Health policy and procedure on privacy, confidentiality and security.

I understand that:

  • all confidential and/or personal health information that I have access to or learn through my volunteer service with Bluewater Health is confidential,
  • as a condition of my volunteer service with Bluewater Health, I must comply with these policy and procedure, and
  • my failure to comply may result in the termination of my volunteer service with Bluewater Health and may also result in legal action being taken against me by Bluewater Health and others.

I agree that I will not access, use or disclose any confidential and/or personal health information that I learn of or possess because of my affiliation with Bluewater Health, unless it is necessary for me to do so in order to perform my volunteer responsibilities. I also understand that under no circumstances may confidential and/or personal health information be communicated either within or outside of Bluewater Health, except to other persons who are authorized by Bluewater Health to receive such information.

I agree that I will not alter, destroy, copy or interfere with this information, except with authorization and in accordance with the policy and procedure.

I agree to keep any computer access codes (for example, passwords) confidential and secure. I will protect physical access devices (for example, keys and badges) and the confidentiality of any information being accessed.

I will not lend my access codes or devices to anyone, nor will I attempt to use those of others. I understand that access codes come with legal responsibilities and that I am accountable for all work done under these codes. If I have reason to believe that my access codes or devices have been compromised or stolen, I will immediately contact my direct supervisor.

I understand that the Hospital will monitor confidentiality by:

  • Performing random reviews of patient charts
  • Reviewing my use of the health care information system when necessary

Please sign, date and return to the Privacy Office, Norman Site. Thank you.

______

SignatureDate Reviewed

STUDENT VOLUNTEER REFERENCE CHECK FORM

Prospective Volunteer: ______

A teacher, coach, clergy, physician should provide a reference.

Family members or friends may NOT provide a reference.

Referee
This individual has applied to volunteer at Bluewater Health. As a volunteer this individual may have contact with patients who are vulnerable, recovering from illness or have special needs. Volunteers assist staff, patients and their families in a variety of ways. Activities may include visiting, offering support and comfort, working in positions of trust and confidentiality. Volunteers are required to work co-operatively with staff, physicians, and other volunteers.
Name of Referee: ______
Signature of Referee: ______Date: ______
Title/Position: ______Organization: ______
Referee Phone #. Bus.: (__) _____-______Ext.: ______
Qualities/Strengths
  1. How long have you known the applicant? ______
  2. In what capacity do you know the applicant? ______
  3. In your opinion, is the applicant:
__ Reliable __ Responsible __ Organized __ Trustworthy __ Compassionate __ Positive
__ Independent __Committed __Co-operative __ Personable __Accepting __ Adaptable
Other comments: ______
4. What strengths or qualities does this individual possess that would be of value in performing volunteer duties: __ Follows instruction __Initiative __ Sound judgement
Other comments: ______
5. What area(s) do you feel the applicant needs to develop or strengthen?
__ Judgement __ Initiative __ Commitment __Interpersonal Skills __Confidentiality __ Co-operation
Other comments: ______
6. Do you recommend the applicant for a volunteer position? __ Yes __ No
Please explain: ______
______
______
Thank you for completing this reference, please place in a sealed envelope and return to the volunteer or fax to 519-464-4494.