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Phoebe Putney Memorial Hospital
Application for Volunteer Service
Prospective Volunteer Letter
* Required
GENERAL INFORMATION
Date: 
Were you referred by a volunteer? 
If so, who? 
Prefix: 
Last Name: 
First Name: 
Middle Initial: 
How do you want your first 
name to appear on badge?: 
Street Address: 
City: 
State: 
Zip Code: 
Home Phone: (xxx-xxx-xxxx) 
Work/Cell Phone: (xxx-xxx-xxxx) 
Email Address: (home or work) 
Date of Birth: 
 
Education / Special Training 
/ Foreign Languages: 
Degrees: 
 
Work Status: 


If presently employed, name of company: 
Work Phone Number: 
Position: 
Work hours and days: 
 
IN AN EMERGENCY PLEASE NOTIFY
Name:   
Relationship: 
Address: 
Home Phone:   
Work/Cell Phone: 
 

Have you ever been convicted of a crime? (I understand that if I have been convicted of a crime, I am not automatically disqualified from consideration for volunteer service; but, that giving false or incomplete information is sufficient cause to disqualify me from volunteer services.)
 
If yes, please explain:
 

VOLUNTEER AVAILABILITY
Monday:       
Tuesday:       
Wednesday:       
Thursday:       
Friday:       
Saturday:       
Sunday:       
 
Additional Availabilty Comments
 

Special area of interest in volunteering:
 
Skills / Comments
 
How did you become interested in our program?
 
What do you hope to gain from your volunteer experience?
 
Have you ever volunteered before?
 
If yes, please describe the experiance.
 
Are there any work activities or conditions that you must avoid?
 

PERSONAL REFERENCES
Please note that complete reference information is necessary to process application. Forms will be sent to references by mail or via email. When complete response information is received, you will be notified for a personal interview.
DO NOT use relatives as references. One reference for whom you have worked is preferred.
Reference 1
Name: 
Phone: 
Address: 
City: 
State: 
Zip Code: 
Relationship: 
Email Address: 
 
Reference 2
Name: 
Phone: 
Address: 
City: 
State: 
Zip Code: 
Relationship: 
Email Address: 
 

The information provided in this application is true in all respects, without any willful omissions. I give my consent for a representative of the Volunteer Office to contact the references listed.

As a VOLUNTEER, I would…
  • agree to attend the volunteer orientation and train until I am competent to perform the required duties;
  • agree to comply with all the rules and regulations of the hospital and the Volunteer Department;
  • understand that I may be dismissed from my duties for willful wrong doing or negligence and/or performing duties outside of my service description;
  • agree to call my assigned area or volunteer office as soon as possible when I have scheduling changes;
  • understand that PPMH is not obligated to utilize my services as a volunteer nor am I obligated to accept the volunteer assignment offered.

CONFIDENTIALITY: It is the belief of this hospital that all medical, financial, and personal information pertaining to a patient is confidential and is protected from unauthorized viewing, discussion, and disclosure. Therefore volunteers may look at, use, or disclose patient information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion, or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

I acknowledge and have read the statements above and agree to abide by the expectations of the Department of Volunteer Services and PPMH.
 
Signature: 
 
Your information will take a moment to process. To avoid duplicate submissions, please do not click on the back button or hit submit more than once.
     
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© 2014 Phoebe Putney Health System  |  417 Third Avenue, Albany, Georgia 31701  |  Telephone 877.312.1167

Phoebe Putney Health System is a network of hospitals, family medicine clinics, rehab facilities, auxiliary services, and medical education training facilities. Founded in 1911,
Phoebe Putney Memorial Hospital (the flagship hospital) is one of Georgia's largest comprehensive regional medical centers. From the beginning, Phoebe's mission and vision
has been to bring the finest medical talent and technology to the citizens of Southwest Georgia, and to serve all citizens of the community regardless of ability to pay.