Student Volunteer Application

Please complete the online registration process which includes submitting the following required forms below. Forms can be downloaded here. Be advised you will not be able to submit this application until the forms below have been downloaded, completed and then uploaded at the bottom of this application form.

1. HIPAA Form. Please click here to download.

2. Multimedia Consent Form. Please click here to download.

3. Health Assessment Form. Please click here to download.

4. TB PPD Medical Surveillence Form. Please click here to download.

5. Parental Permission Form (IF UNDER 18 this must be signed!). Please click here to download.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Where are you applying to volunteer?

* First name

Preferred Name (If Different From First Name)

Middle name

* Family/last name

Name suffix

* Last 4 of S.S.

Gender

* DOB

E-mail address

* Phone (Home)

Phone (Mobile)

* Address

Address 2

* City

State

* Zip/postal

Emergency Contacts

(Daytime)

* Parent 1

* Parent 1 Phone

Parent 2

Parent 2 Phone

Other

Other Phone

Education

School or College Attended

Present GPA

Degree/Year in School

About You

Portrait photo

Career Interests

Paid Work Experience

Volunteer Work Experience

Hobbies, Skills, Languages

Do you, or might you have a job that could interfere with volunteering?

If so, please describe

Do you need the same time schedule as anyone else?

If so, who?

If the above could not volunteer, would you still be able to come to the hospital?

Availability

Please indicate the days and hours you would prefer

Sunday

9am-5pm

9am-1pm

1pm-5pm

Monday

9am-5pm

9am-1pm

1pm-5pm

Tuesday

9am-5pm

9am-1pm

1pm-5pm

Wednesday

9am-5pm

9am-1pm

1pm-5pm

Thursday

9am-5pm

9am-1pm

1pm-5pm

Friday

9am-5pm

9am-1pm

1pm-5pm

Saturday

9am-5pm

9am-1pm

1pm-5pm

References

Please list at least 2 recent references: (References must be a former/current employer or someone other than friend or family who can vouch for your character).

Reference 1

* Name

* Address 1

* City

* State

* Zip/postal

* Phone

* E-mail

Relationship

Reference 2

* Name

* Address 1

* City

* State

* Zip/postal

* Phone

* E-mail

Relationship

Reference 3

Name

Address 1

City

State

Zip/postal

Phone

E-mail

Relationship

Tell Us More

* How did you hear about volunteer opportunities at Danbury Hospital?

* Please tell us why you feel you should be selected to participate in this years program; what you hope to learn from this experience, and highlight what others would say makes you unique.

Final Steps

* HIPAA Form

* Multimedia Consent Form

* Health Assessment Form

* TB PPD Medical Surveillence Form

Parental Permission Form, if under 18

I certify that the information in this application is correct to the best of my knowledge. I authorize the investigation of all matters contained in this application and agree that any misleading or false statements shall be cause for rejection of this application and will be cause for immediate dismissal.

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Signature