Volunteer interest form

At Gundersen, our volunteers are love in motion—and an integral part of our healthcare team. The first step to making a difference in our patient's lives is completing this volunteer interest form.

Basic information

First

Middle

Last

Suffix

Phone

Local address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Do you have a different permanent address?

Yes

Permanent address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Date of birth

Education

School name

Highest degree acquired

Are you currently a student?

Yes

Major

Year in school

Employment

Are you currently employed?

Yes

Employer

Employer phone number

Position/type of work

Approximately how many hours per week do you work?

Why do you want to volunteer at Gundersen?

Please provide us with a bit more information about yourself, why you want to volunteer, what your goals are, and what your preferred service areas are.

Please describe any relevant experience.

Do you have any education, training, work experience, etc that would be beneficial as a volunteer at Gundersen?

Terms of 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 UNDERSTAND THAT IF ACCEPTED AS A VOLUNTEER:*

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.