Volunteer Application

• Hospital Name:* Select a hospital Allegheny General Hospital Allegheny General Hospital Suburban Campus Allegheny Valley Hospital Canonsburg General Hospital Forbes Hospice The Western Pennsylvania Hospital Forbes Regional Hospital

• First Name:*
• Last Name:*
• Gender:* Male   Female
• Address (street, apt #, city, state, zip):
• Home Phone:*
• Cell Phone:
• E-mail Address:*
• Were you previously a West Penn Allegheny Health System volunteer?* Yes   No

• Why did you select West Penn Allegheny Health System for Volunteer Service?*
• Education (Please list schools attended, degrees and diplomas earned)*
• Work Experience (Please list Employment and Dates)
• Volunteer Experience
• How would you most like to help us?* Help Patients
  Visitor/Family Support
  Gift Shop
  Fund-Raising
  Clerical Support
  Research (AGH only)
  Other:
• Skills, Hobbies, or Interests*
• Special Needs:
• Days Available:* Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
  Sunday
  
• Hours Available:* From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  From:   To:
  
• Are you related to any employee or staff member of West Penn Allegheny Health System?* Yes   No
  

• Have you ever been employed by West Penn Allegheny Health System?* Yes   No
  

• Are you required to perform court ordered community service?* Yes   No
  
• Have you ever been convicted of a felony?* Yes   No
  

• Name:*
• Relationship:*
• Phone/Address*

• Name:*
• Relationship:*
• Phone/Address*

• Name:*
• Relationship:*
• Phone/Address*

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief and have been given voluntarily. I understand that West Penn Allegheny Health System requires certain information both personal and professional from me to evaluate my qualifications and consider me for volunteer services. I understand that in consideration of my application, a background investigation may be conducted. I hereby grant West Penn Allegheny Health System permission to verify such answers and investigate all references, and conduct such further investigation as is necessary, including, but not limited to, the performance of medical examinations, drug screening, reference verification, military service verification, and criminal background checks. I understand that any false statements or incomplete information on this application may be considered sufficient cause for rejection of this application or for dismissal if such information is discovered subsequent to my volunteer work. I authorize any past and present employers, personal references, and other organizations, to answer all questions asked concerning my previous employment and/or volunteer record, ability, character, educational background, military service, or criminal history. I hereby release all employers, persons or organizations, from any liability whatsoever for providing this information. I understand that I may be asked to discontinue my volunteer services at any time for any reason. I understand that West Penn Allegheny Health System will not be responsible for any personal injury or property loss that may occur to me while performing volunteer services.

I understand that I will not receive any monetary compensation from West Penn Allegheny Health System, individual employees or anyone else for serving as a volunteer. I hereby agree to abide by all policies and procedures of West Penn Allegheny Health System. I will treat information regarding patients and employees in strict confidence.

By submitting this application I agree with the Applicant’s Certification.