Hospice volunteer interest form

I understand and agree that at no time will any information regarding patients of Gundersen Health System be revealed to anyone other than those authorized to receive it. I understand that the giving of information concerning a patient to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.

I agree to any necessary health screening required by Gundersen Health System and understand my volunteer assignment is contingent upon successful completion of this screening. I understand that any false statements made as a part of this application may be considered sufficient cause for dismissal. 

Should the volunteer orientation process move forward - I authorize permission for all named references to release personal and professional information to the Volunteer Services office. I also consent to a background check. I further release Gundersen Health System, as well as those supplying said information, from any and all liability from these investigations.

• I will abide by Gundersen Health System’s general policy concerning patient confidentiality.
• My assignment is on a probationary basis for a period of 90 days.
• I voluntarily offer my services with a clear understanding that there is no monetary compensation.
• I will observe all Gundersen Health System’s regulations.
• A minimum six month commitment or full school semester is required.

By typing your name, you are electronically signing this form.