Middlesex Health

Adult Volunteer Application

Thank you for your interest in volunteering at Middlesex Health.

Please complete all required fields below to establish your applicant profile and apply for a volunteer position.

Applications are reviewed by our Volunteer Coordinator in a timely manner.

* I am over the age of 18. I am NOT a High School nor a College Student.

Application Information

* First name

* Family/last name

* Street Address

Apt/Unit #

* City

* State

* Zip/postal

Phone (Home)

* Phone (Mobile)

* E-mail

*Date of Birth-Month

* *Date of Birth-Day

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Emergency Contact Information

* Contact name

* Phone

* Relationship

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Education Information

*Highest Level of Education Completed

School Name:

*Have you graduated?

If currently attending college/university, please state your anticipated month and year of graduation in the box below:

Would this volunteer opportunity be utilized for a college requirement? (Please select one of the choices below)

If YES, please return to the main page and start a 'College Student' Volunteer Application form.

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Current/Most Recent Employer Information

Position held: (If Student or Homemaker, please state that in the box below)

Current/Most Recent Employer

Supervisor Name

Supervisor Phone Number

Employment Start Date (Month & Year)

Employment End Date (Month & Year) and if still currently employed, please type 'Still Employed':

Are you now or have you ever been employed by Middlesex Health ?

If yes, please select your facility below

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Volunteer Experience

Volunteer source

Do you have any previous volunteer experience? (Please select from one of the choices below)

If YES, please list any current or previous volunteer experiences in the box provided below:

Please list any skills or interests that may be applicable to your volunteer service (ex. proficiency in a foreign language or sign language, Reiki ceritifcation, play a musical instrument, etc.) in the box below:

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Daily Availability

Please tell us when you are available. (Check all that apply)

Daily Availabilty: Monday

Daily Availability: Tuesday

Daily Availability: Wednesday

Daily Availability: Thursday

Daily Availability: Friday

Daily Availability: Saturday

Daily Availability: Sunday

* First Date Available:

* Please share your reason(s) for volunteering:

Community Service Requirement

If yes, please list how many hours your need to complete

Date of Community Service completion:

Service Position Desired

Behind the Scenes- assist staff with clerical duties, such as filings, data entry, deliveries, etc.
Customer Service- assist patients and visitors navigating the hospital, greeting, escorting, working in our Gift Shops or Information Desk/Lobby Ambassador.
Patient Support- assist patients and staff on units such as transporting, sanitizing, provide blankets/water, etc.

Please check the type of assignments you prefer from the following list: (Check all that apply)

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Applicant Statement

Please check the box below to acknowledge and agree with the following statements:

I understand incomplete applications will not be considered for processing.
I understand that documentation of proof of vaccination of measles, mumps and rubella (MMR) vaccine or laboratory evidence of immunity, proof of vaccination of 2 doses of the Varicella vaccine (vaccine for chicken pox) or laboratory evidence of immunity or history of chickenpox based on healthcare provider diagnosis, and Tuberculosis screening via a 2-step TB (PPD) skin test [If positive, chest X-ray is required], or Quantiferon Gold (preferred) will be required to volunteer with Middlesex Health.
I understand that a flu vaccine is required in season.
I agree to abide by the policies and regulations of Middlesex Health and the Volunteer Services Department and to participate in orientation and training required by Middlesex Health.
I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.
I understand that I may be dismissed from my duties if I fail to comply with health system policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the Director of Volunteer Services to the best interests of the health system.
I authorize Middlesex Health to take my photograph in relation to my volunteer position.

* I certify that the facts set for in the applications are true and complete to the best of my knowledge.

* I understand and agree that submitting this application form does not automatically register me as a Middlesex Health Volunteer.

* Typing in your name confirms your signature.

* Application date

To submit your completed application, please press the Save button. Thank you for submitting your application. A confirmation message has been sent to your email.