VOLUNTEER APPLICATION

(PLEASE TYPE OR PRINT NEATLY)

LAST NAME:

FIRST NAME:

MIDDLE NAME:

ARE YOU OVER AGE 18?

YES NO

E-MAIL ADDRESS:

CELL PHONE NUMBER:

MAILING ADDRESS:

CITY:

ZIP CODE:

HOME PHONE NUMBER:

DATE OF BIRTH: (optional)

LAST 4 DIGITS OF SOCIAL SECURITY #

SEX:
FEMALE MALE

SCHOOL ATTENDING / ATTENDED:

FIELD OF STUDY:

CAREER GOAL:

EMPLOYER:

OCCUPATION:

WORK NUMBER:

EMERGENCY CONTACT PERSON:

RELATIONSHIP TO APPLICANT:

EMERGENCY CONTACT PHONE NUMBER:

WHY ARE YOU INTERESTED IN VOLUNTEERING FOR UC SAN DIEGO HEALTH SYSTEM?

__________________________________________________________________________________________________

Do you currently
(or have you ever)
worked for UCSD?

__________________________________________________________________________________________________

YES NO
PLEASE LIST SKILLS AND QUALITIES THAT YOU FEEL WOULD BENEFIT AND/OR ENHANCE OUR PROGRAM:

ORIENTATION DATE:

_________________________________________________________________________________________________
FLUENT LANGUAGE(S):

_________________________________________________________________________________________________

CONFIDENTIALITY AND COMMITMENT STATEMENT:

I understand and agree that in the performance of my duties as a volunteer at the UCSD Medical Center I must abide by all policies and
procedures, including to hold as strictly confidential all medical information that I may obtain directly or indirectly concerning patients. I
understand that failure to comply with these requirements may result in my dismissal as a volunteer.
I am volunteering my services to the University of California solely for my personal purposes or benefit without promise or expectation of
compensation or University benefits. I agree to serve as a volunteer without salary for a period of 100 hours or more. As the guardian of
stated volunteer, I hereby give consent for TB screening given by UCSD Medical Center.
Have you ever been convicted of a felony or misdemeanor which resulted in imprisonment, probation, or a fine of more than $500?
YES NO If yes, please explain below. A conviction will not necessarily disqualify you from volunteering.
_______________________________________________________________________________________________________________________
Volunteer's Signature __________________________________________________ Parent's signature, if under 18 ___________________________________________

OFFICE USE ONLY

INTERVIEW DATE:

VOLTRAK #:

IMMUNIZATION CLEARANCE:

Measles
Rubella

Mumps
Varicella

Influenza ____________

TB CLEARANCE(S):

ORIENTATION HOURS:

TYPE:

YES NO

_______________________
_______________________

PARKING
PERMIT/AGREEMENT:

YES NO

DATE(S): _______________________
_______________________

WORK AREA:

DATE BADGE RECEIVED:

BACKGROUND CHECK SENT:

ON-LINE COURSE
COMPLETED:

ON-LINE REGISTRATION:

DEPARTMENT NOTIFIED : YES _________________

START DATE:

NOTES-OFFICE USE ONLY:

Volunteer Services; 200 West Arbor Drive, San Diego, CA 92103-8959; Telephone: (619) 543-6370; http://health.ucsd.edu/volunteer