Miami University Student Volunteer Application Form

Last Name: *

First Name: *

Middle Name:

Address: *

City: *

State: *

Zip: *

Local Phone: *

Cell Phone:

E-mail address: *

Permanent Address:

Permanent City:

Permanent State:

Permanent Zip:

Permanent Phone:

In case of emergency, contact

Name: *

Address: *

Phone: *

Work Phone:

Please select your current age group: *
14-17 years of age
18 years of age or older

Month/Year you plan to graduate: *

Major:

If presently employed, provide name of firm:

Position:

Work hours and days:

How did you become interested in our volunteer program?

Have you volunteered or worked for McCullough-Hyde in the past? *
Yes
No

Days and times you are able to volunteer: *

Previous Volunteer Experience:

Education/career interests and goals:

Hobbies, skills, activities and interests:

Please give any additional information you feel may be pertinent to your application:

Have you've been convicted of a crime? (Considered only as it relates to fitness to perform the volunteer position being sought) *
Yes
No

References

The references below will be sent a letter via email, so please be sure to provide their email address. Do not use immediate family members as references.

Reference 1

1. Name: *

Phone: *

Address: *

E-mail:

Reference 2

2. Name: *

Phone: *

Address: *

E-mail:

The information I provided is accurate and correct to the best of my knowledge. I give permission for McCullough-Hyde Hospital to check my references. Required

Furthermore, I understand that my signature indicates approval for MHMH to perform a background check and/or request fingerprints. Please be aware that McCullough-Hyde Memorial Hospital, Inc. is not obligated to provide volunteer placement, nor are you obligated to accept a position.

Electronic Signature: *

Date: *

Opportunities for volunteers are provided without regard to creed, race, national origin, age or sex.

McCullough-Hyde is a smoke free and tobacco free campus.

This position is not an employee position and is not paid for the services rendered.

Influenza vaccines are mandatory and documentation should be submitted to volunteer services by November 1 of each year. TB testing (tuberculosis) is required before volunteering. This can be done in our Immunology Clinic free of charge. Call 513.524.5566 for hours. Also, a copy of your immunization records (showing MMR and Hepatitis B) will be collected from you before volunteering.

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