Volunteer Application

Thank you for your interest in volunteering at Dupont Hospital. Volunteers are accepted based upon their abilities, availability and our specific needs for people to provide service to our patients and support to those providing care for patients. All prospective volunteers or employees receive a routine background check which requires your SSN. This application asks for the name and address of two people who can attest to your good character and suitability to be a volunteer.

About You


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For Minors Only

Personal References:
(Students: List one teacher and a second person)

Reference 1

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Reference 2

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Reference 3

Schedule

(Check days and times you are interested in volunteering)
  Mon. Tue. Wed. Thu. Fri. Sat. Sun. Any day As needed
AM
PM
Eve.

Special Job Skills or Interests

Job, Volunteer or Community Service Experience: List below your present and past work/volunteer experience beginning with your most recent.

Company, Organization 1

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Company, Organization 2

Physical and Medical Background

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Education

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Indicate Number of years completed
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Certificate of Applicant

The facts contained in this application for volunteer work are true and complete. I understand that if I become a volunteer, any false statements on this application will be cause for release from the program. I authorize Lutheran Hospital to contact my current and/or former employers or work. I authorize such employers, the police department and other volunteer agencies to release my information to Lutheran Hospital regarding my qualifications, past work experience, work performance, employment status, character, behavior and any other information related to my work history and/or suitability for volunteering. I agree that all questions asked and information released in good faith shall be privileged, and I expressly release the Lutheran Hospital and any of its authorized representatives from any and all liability arising from questions asked, information released or statements made in good faith.

Agreement: I agree to adhere to the policies and procedures of Lutheran Hospital and Volunteer Central. I have no expectation of compensation and I am donating my time for personal reasons.


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Medical Release

I hereby authorize Lutheran Hospital Associates to provide emergency care to me in the event of illness, accident or injury while I am volunteering at the Hospital.


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If applicant is a minor

 
LUTHERAN HEALTH NETWORK
BLUFFTON REGIONAL MEDICAL CENTER | DUKES MEMORIAL HOSPITAL | DUPONT HOSPITAL* | KOSCIUSKO COMMUNITY HOSPITAL*
LUTHERAN HEALTH PHYSICIANS | LUTHERAN HOSPITAL* | MEDSTAT | THE ORTHOPEDIC HOSPITAL* | REDIMED | REHABILITATION HOSPITAL*
ST. JOSEPH HOSPITAL*

*A physician owned hospital.

If you are experiencing a medical emergency, call 911.
*ER wait times are door to clinical professional and can change quickly depending on the urgency of patients that arrive by ambulance. Lutheran Health Network provides care to patients with life-threatening illnesses first.
Patients are seen in order of severity, therefore, your spot may not be guaranteed. In case of a life-threatening emergency, call 911.
Dupont Hospital is owned in part by physicians.
Patient results may vary. Consult your physician about the benefits and risks of any surgical procedure or treatment.