Hanover & District Hospital - Student Volunteer Application

Please ensure that all questions are completed as fully as possible. All volunteer information is held in strict confidence.

Fields marked with an asterisk (*) must be filled out.

Name:*

School:*

Grade:*

Telephone (Home):*

Telephone (Work):

Email Address:

Address:*

Birth Date :*

Emergency Contact Name :*

Emergency Contact Relationship :*

Emergency Contact Phone (Home):*

Emergency Contact Phone (Work):

Languages Spoken :*

English
French

Other Languages Spoken :

I want to volunteer at the hospital to (please check where applicable) :*

help others
meet people
explore career opportunities
learn new skills
keep busy
personal satisfaction
show appreciation for help received
meet educational requirements

I am able to volunteer: (please check where applicable) *

I heard about volunteering at the hospital from (please check where applicable) :*

hospital staff
the library
hospital volunteer
my school
visiting hospital
local newspaper

Previous Volunteer Experience:

References: (Please check box to agree) *

I hereby authorize Hanover & District Hospital to contact, in strict confidence, the following references. One should be a school Counsellor or Teacher (NOT a friend or relative) and a full mailing address including postal code should be provided. It is suggested that you ask each person whether or not you may use him/her as a reference. Thank you.

Reference #1 Name:*

Reference #1 Occupation :*

Reference #1 Telephone :*

Reference #1 Address including city and postal code:*

Reference #2 Name:*

Reference #2 Occupation :*

Reference #2 Telephone :*

Reference #2 Address including city and postal code:*

Confidentiality Agreement : *

I understand and agree that in the performance of my duties, I will respect the privacy of patients and staff at Hanover and District Hospital. As a volunteer, I will hold in confidence all confidential matters that come to my attention and will not use this information for personal gain. I will not attempt to access information that I have not been authorized to deal with and is not outlined in my position description. I will discuss client information only in designated areas with persons who require the information for delivery of care or services.

I agree with the above confidentiality agreement
I do not agree with the above confidentiality agreement

Students under 18 years of age require parent/guardian authorization to volunteer at the Hospital.

If you are under the age of 18 your parent/guardian will be required to sign a consent form for your participation in the Hanover and District Hospital Student Volunteer Program as well as an authorization for you to receive a Mantoux Tuberculosis Skin Test prior to serving as a volunteer.