McLaren Lapeer Region Volunteer Application Form

Note: Fields marked with an * indicates required field

McLaren Lapeer Region
Volunteer Application Form

Last Name: *

First Name: *

Middle Initial:

Street Address: *

City - State - Zip: *

Daytime Phone Number: *

Evening Phone Number:

Cell Phone Number:

E-mail Address:

Gender: *

Male

Female

Michigan Drivers License Number: *

Date of Birth: *

Marital Status: *

Single

Married

Are you aware of any medical, physical or mental handicap that would affect your ability to perform volunteer duties?:

Yes

If yes, please explain:

Are you presently engaged in any activity at McLaren Lapeer Region?:

yes

If yes, please explain:

Are you preparing for any special career?

yes

If yes, please explain:

Education:

High School

College

Other

If other describe:

Are you presently a student?

yes

If yes, where:

Please list any special skills or abilities you possess:

typing	filing
sign language	other

If other:

Community Affiliations:

I am interested in becoming a volunteer because:

Employment

Are you currently employed?

yes

Dates of Employment:

Employer and Postion:

Phone Number:

Previous Employer and Position:

Dates of Employment:

Have you ever been a volunteer?

yes

If so, when:

References (Other than relatives)

Name: *

Phone: *

Street Address: *

City, State, Zip Code: *

Name: *

Phone: *

Street Address: *

City, State, Zip Code: *

Emergency Contact:

Name: *

Relationship to you: *

Phone: *

Address: *

City, State, Zip: *

Preferred Service and Time

Service Area Preferred:

Days Preferred:

Monday-Fri

Weekends

Holidays

Hours Preferred:

Mornings

Afternoons

Evenings

BACKGROUND CHECK (To protect your privacy, this form will only be seen by MLR Volunteer Services staff)

Have you event been convicted of a felony or misdemeanor?

yes

If yes, please explain:

Please indicate any other name(s) ever used:

I GIVE MCLAREN LAPEER REGION PERMISSION TO CHECK MY CRIMINAL HISTORY WITH MICHIGAN LAW ENFORCEMENT AGENCIES, AND TO SEARCH MY HISTORY FOR INCIDENTS OF FRAUD WITH THE FRAUD AND ABUSE CONTROL INFORMATION DATABASE. I AUTHORIZE MCLAREN LAPEER REGION AND ITS AFFILIATES OR IT’S DESIGNATED AGENTS TO MAKE WHATEVER INQUIRES IT MAY DEEM NECESSARY IN CONNECTION WITH MY VOLUNTEER APPLICATIONS. AS PART OF SUCH INQUIRES, MCLAREN LAPEER REGION HAS MY PERMISSION TO CONTACT PERSONS WHO MAY HAVE INFORMATION RELATING TO MY SUITABILITY FOR VOLUNTEER WORK. I FURTHER AUTHORIZE MCLAREN LAPEER REGION, IN ITS SOLE DISCRETION TO FURNISH COPIES OF THIS AUTHORIZATION AND MY VOLUNTEER APPLICATION TO ANY PERSONS IN CONNECTION WITH THE ABOVE PROCESS.

I UNDERSTAND THAT MY ENROLLMENT AS A VOLUNTEER IS CONTINGENT UPON SUCCESSFUL COMPLETION OF THE APPLICATION PROCESS. FOR MY CRIMINAL HISTORY TO BE VERIFIED AND TO HAVE MY HISTORY SEARCHED FOR FRAUD AND ABUSE. I AGREE TO RELEASE MCLAREN LAPEER REGION, IT’S AFFILIATES, AND ALL PARTIES FROM ANY LIABILITY FOR ANY DAMAGES THAT MAY RESULT FROM FURNISHING SUCH INFORMATION.

IF I AM SELECTED AS A MCLAREN LAPEER REGION CENTER VOLUNTEER I AGREE TO ABIDE BY ALL HOSPITAL RULES, REGULATIONS AND EXPECTATIONS. I UNDERSTAND THAT EITHER PARTY MAY CANCEL THIS RELATIONSHIP AT ANY TIME.

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO INFORM MCLAREN LAPEER REGION OF ANY CHARGES.

Applicant Signature: *

Date:

Note: A criminal history will not necessarily disqualify an applicant. A criminal record is one piece of information that will be considered in determining the appropriates of an individual to be a McLaren Lapeer Region Volunteer

AS A VOLUNTEER, YOU WILL HAVE THE OPPORTUNITY TO LEARN A GREAT DEAL ABOUT THE HEALTH CARE INDUSTRY. THE EXPERIENCE THAT YOU ACQUIRE MAY BE OF VALUE IN THE FUTURE. HOWEVER, THAT FACT THAT YOU HAVE BEEN ACCEPTED AS A VOLUNTEER BY MCLAREN LAPEER REGION IS NOT TO BE CONSTRUED IN ANY MANNER AS A GUARANTEE OF FUTURE EMPLOYMENT OR A COMMITMENT THAT YOU MAY BE CONSIDERED FOR OR OFFERED EMPLOYMENT BY THE MEDICAL CENTER AT SOME FUTURE DATE.

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