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UI Health Care Community Volunteer Preregistration Application

Thank you for your interest in volunteering at University of Iowa Hospitals & Clinics and UI Stead Family Children's Hospital!

Please submit this form to preregister as a UI Health Care Volunteer. If you experience any difficulty while filling out this form, please contact volunteerservices-vsys@uiowa.edu.

Once our staff has reviewed your form, we will be in touch with more information within 5 business days.

We look forward to helping you make a difference!

All fields marked with * are required.

General Information

* Legal first name*

Middle name

* Last name*

Preferred first name

* Date of birth* (MM/DD/YYYY)

Gender

* Local street address*

* City*

* State*

* ZIP code*

* Phone number*

* Email*

Volunteer Experience

* Please list previous and current volunteer experience*

This volunteer work is a requirement for school credit

This volunteer work is for assigned community service hours

If either of the above is yes, please explain:

* How did you hear about Volunteer Services at UIHC?*
If you were referred to us, please indicate who referred you.

* Do you have a volunteer assignment preference?* (No particular placement can be guaranteed in advance)

* What are your skills and interests?*

Education

Please list your education history*

* School 1
Name of school

Area of study

Years attended

Degree obtained

School 2
Name of school

Area of study

Years attended

Degree obtained

School 3
Name of school

Area of study

Years attended

Degree obtained

Additional training or certifications

University of Iowa ID number (if applicable)

Employment History

Are you currently employed?*

Please list your employment history dating back five years*

Job 1
Employer

Position and duties

Dates employed

Reason for leaving

Job 2
Employer

Position and duties

Dates employed

Reason for leaving

Job 3
Employer

Position and duties

Dates employed

Reason for leaving

Job 4
Employer

Position and duties

Dates employed

Reason for leaving

Please list any family members employed at UIHC
Include names, departments, and relationship to you

References

Provide three references (professional references preferred; no relatives or personal physicians)*
NOTE: Three references are required. Applications submitted with fewer than three references will be rejected.

* Reference 1
Name

* Address/Email

* Phone number

* Relationship to you

* Reference 2
Name

* Address/Email

* Phone number

* Relationship to you

* Reference 3
Name

* Address/Email

* Phone number

* Relationship to you

Health and Emergency Information

* Emergency contact name*

* Relationship to you*

* Emergency contact phone number*

Please specify any physical limitations that would limit your volunteer experience, if any

Background Information

University of Iowa Health Care must be able to assure the safety of all patients in their care. Therefore, we ask you to provide us with the following information which will remain in the strictest confidence, which means that we shall use our best efforts to ensure that the following information will not be released other than to comply with a court order, subpoena, or as otherwise required by law. Otherwise such information will only be used to determine your suitability for placement. The existence of a criminal conviction history is considered only to the extent that it relates to a particular volunteer position.

Have you ever been convicted for violation of any municipal, county, state, or federal law other than a minor parking violation?*

Have you ever been reported for child abuse and/or neglect to the Department of Health and Human Services or a similar agency in any state?*

Have you ever been terminated, suspended, placed on probation, or otherwise penalized for abuse or maltreatment of any person?*

If you answered 'Yes' to any of these questions, please provide date(s), description(s), and an explanation of the incident(s)

Note: In addition to answering these three questions, all volunteers must pass a full criminal background check before they can begin volunteering.

Short Essay

* In the space below, please write a short essay answering the following questions:*
What do you wish to gain from volunteering?
What will make you a successful, dependable volunteer?

Volunteer Commitment Agreement

I understand that to become a UI Health Care volunteer, I am required to make a commitment to volunteering three hours per week for a period of six consecutive months following my placement in a unit. This equates to over 72 total hours. Considerable hospital resources are dedicated to screen, collect background information, health screen, photo ID badge, and appropriately orient, assess, train, place, and supervise volunteers at the hospital, all of which are provided at no cost to me. In addition, the dependability of volunteers directly affects the quality of the placements available to me, particularly in areas with direct patient contact.

With this in mind, I have considered my obligations, and should I be accepted as a UI Health Care volunteer, I pledge to contribute three hours per week for a minimum of 72 total hours.

* By checking this box and typing my name below, I confirm that I both understand and agree to the above commitment.*

* Full name*

Declaration and Application Signature

As a UI Health Care volunteer, I understand that Volunteer Services reserves the right to terminate any volunteer status as a result of (a) failure to comply with hospital policies, rules, and regulations; (b) absences without prior notifications; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgement of the Volunteer Services Director, would make my continued services as a volunteer contrary to the best interests of the hospital. In addition:

* By checking this box and typing my name below, I confirm that I understand the above, and I certify that the statements made in this volunteer application are true, correct, and have been given voluntarily. Any falsification or significant omission of information may result in my rejection or dismissal from participation in UI Health Care Volunteer Services.*

* Full name*

Nondiscrimination Notice

The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, creed, color, religion, national origin, age, sex, pregnancy, disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity, associational preferences, or any other classification that deprives the person of consideration as an individual. The university also affirms its commitment to providing equal opportunities and equal access to university facilities.

For additional information on nondiscrimination policies, contact the Director, Office of Equal Opportunity and Diversity, the University of Iowa, 202 Jessup Hall, Iowa City, IA 52242-1316, 1-319-335-0705 (voice),1-319-335-0697 (TDD), diversity@uiowa.edu.