Anderson Application

Personal Information

* Last name

* First name

Middle name

* Street Line 1

Street Line 2

* City

State

* Zip

* E-mail

* Cell Phone

Home Phone

Work Phone

* Emergency Contact Name

* Emergency Contact Relationship

* Emergency Contact Phone

Family Physician Name

Family Physician Phone

Teen Volunteers Only (16-17 years of age)

Name of High School

Year of Graduation

Year in High School

As a parent/guardian I consent to let Community Hospital Anderson administer a TB skin test (Mantoux) to my son/daughter

Date

Phone

Additional Information

Tell us why you have an interest in volunteering:

How did you find out about our program?

Highest education

If you are a college student, what is your major or field of study?

Do you have a current Indiana Driver's License?

Do you have your own transportation?

Have you ever been convicted of or pled guilty to a felony or misdemeanor other than a minor traffic violation? If yes, explain:

Hospital employees/Auxiliary members at Community Hospital acquainted with:

List any limitations:

Have you ever been employed by Community Health Network or Affiliate?

If Yes, position(s):

Personal References

Do NOT list relatives or former employers:

Reference 1:

Name:

Address, City/State/Zip

Phone Number

Years Known

Reference 2:

Name:

Address, City/State/Zip

Phone Number

Years Known

Job, Volunteer or Community Service Experience and Affiliations:

List below most recent employment or volunteer experience.

Be sure to include previous employment with Community Hospital Anderson and any military experience.

Name and Address

From

To

Reason for Leaving

Position(s) Held

Type of Buisness

Immediate Supervisor's Name and Title

Preferences / Availability

Please check all special skills and interests:

Skills

Service Preferences

Availability (Check all that apply)

Anderson: Availability

Confirmation

PLEASE READ CAREFULLY

I will consider as confidential all information which I may hear directly or indirectly concerning a patient, a doctor, or any member of hospital personnel. I will not express curiosity in regard to a patient beyond the carrying out of my duties.

The facts contained in this application are true and complete. I understand that if I became a volunteer, any false statements on this
application will be cause for release from the program. I authorize Community Hospital Anderson to contact my current and/or
former employers or volunteer agencies and any other person who may have information bearing on my suitability for volunteer
work. If accepted as a volunteer, I will fulfill my commitment of service and maintain annual education and health testing. I
authorize Community Hospital Anderson to complete the Criminal History Check.

[ clear ]

Signature:

General Information for Volunteer Applicants

Health Screening: TB screening is required with the Employee Health Department located at Community Hospital
Anderson. A flu shot is also required. These are provided at no cost to the volunteers.

Criminal History Check: All new volunteers over the age of 18 must pass a criminal history background check by the
Indiana State Police.

Orientation: all volunteers are required attend volunteer orientation. You will be given important resources that should
be studied. Additional training will occur, depending on your specific volunteer assignment. In some cases, you will
shadow a current volunteer or hospital employee in your designated area.

Uniforms: Uniforms are provided to each volunteer. A name badge will be provided and is to be worn on your uniform
at all times. Uniforms must be worn while volunteering. The dress code consists of black, khaki or white pants, the
under shirt of your choice, with your Community Hospital Anderson smock, vest or polo shirt over it. Shoes must be
closed toed and heel covered. When a volunteer ends their service to the hospital, they are required to turn in their
name badge to the Volunteer Services office.

Parking: Parking is free. You will be instructed on where to park in Orientation.

Meal: One free meal (totaling $7 or less) will be provided on the day you volunteer.

Sign in/out: Volunteers sign in and out using a touch screen computer. You will be trained on this procedure. Service
hours are tallied from these records, as well as annual hospital reports and are available for you for scholarship
applications, tax purposes, etc.

Attendance: Volunteers and staff have a better experience if volunteers commit to a consistent schedule. If you cannot
volunteer due to illness, vacation, etc., please contact the Auxiliary office at 765-298-5100 or the CHA employee with
whom you volunteer.

Again, welcome to our team and thank you for helping us always create exceptional experiences for our patients,
families, staff and guests at Community Hospital Anderson. If you have any questions, please don't hesitate to contact
us. We look forward to working with you!

Sincerely,
Lorie Staehler
Volunteer Services Director

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VSys Anderson Application