1. law, govt and politics
2. law enforcement
3. fire department

Providence Newberg Medical Center
Community Connections
310 Villa Road, Suite 110
Newberg, OR 97132
t: 503-537-1549
Dear Volunteer Applicant,
Thank you for your interest in volunteering with one or more of Providence Newberg Medical Center’s Community
Connections programs. Providence seeks volunteers willing to join us in carrying out our mission to reveal God’s love for all,
especially the poor and vulnerable, through our compassionate service. Your service as a volunteer will contribute
significantly toward this end and toward Providence’s high standards for service excellence.
Enclosed you will find the volunteer application and background and health disclosure forms for all volunteer opportunities
associated with Providence Newberg. Volunteer applicants will be contacted for an interview based on openings, interest,
and qualifications.
Please complete all of the following pages and return to:
Providence Community Connections
310 Villa Road, suite 110
Newberg, OR 97132
Providence Newberg Medical Center’s Volunteer screening and placement process include the following. As a
Providence volunteer you will need to:
 Make a minimum commitment of six or more months (hourly commitment varies depending on assignment,
please inquire with Coordinator)
 Submit a completed and signed volunteer application, background, and health disclosure forms (attached)
 Schedule and attend an in-person interview
 Obtain a TB test, provided at no charge by Providence Newberg Medical Center (optional for some)
 Obtain an ID badge
 Obtain a volunteer uniform (if applicable)
 Attend a volunteer orientation (held once a month)
 Participate in periodic volunteer meetings and training
 Sign in and out (or track as applicable) for each shift worked
 Return volunteer badge and uniform upon completion of service
The Community Connections will:
 Interview potential volunteers as openings occur and determine if the volunteer opportunity is a mutual match
 Submit a background check on all volunteers 18 years and older, including a criminal history and social security
number verification
 Provide volunteer orientation and training for the specific volunteer placement
 Issue a volunteer ID badge and uniform
 Maintain ongoing communications to help volunteers gain enriching experiences and excel in providing quality
service
Providence Newberg Medical Center appreciates and values the dedication and hours of service each and every
volunteers contributes throughout the year. Thank you again for your interest in being part of our volunteer team at
Providence Newberg Medical Center.
For additional information, please inquire about Providence Newberg Medical Center volunteer opportunities at (503)
537-1494 and community based volunteer opportunities at 503-537-1549.
VOLUNTEER APPLICATION
Date:
Are you an:  Adult  Student  Providence Employee
Internal Use: Application received
by (Coordinator date & initial):
PERSONAL INFORMATION
Name: ___________________________________________________________________________________________
Last
First
MI
Mailing Address: ___________________________________________________________________________________
Street Address: ____________________________________________________________________________________
City: _________________________________________ State: _____________________ Zip: ______________________
Home Phone: ________________________ Cell: ______________________Work: ______________________________
Email: ________________________________________________________ Birth date: __________________________
Marital Status: __Married __Single __Divorced __Widowed __Other
Where did you hear about us? ________________________________________________________________________
Faith Community (not required to apply, disclosure is optional):
EDUCATION / TRAINING
Present Occupation / Employer: ________________________________________________________________________________
Position / Years of Service: _____________________________________________________________________________
Other Skills / Responsibilities: __________________________________________________________________________________
Education / Course of Study: _______________________________ Current Student?  Yes  No
High School Name: __________________________________________ Class: _____________________________________
College Name: ______________________________________________ Class: _____________________________________
Special Training / Other Certification:____________________________________________________________________________
What languages do you speak? _________________________________________________________________________________
Have you volunteered before?______________________________ Organization: ______________________________________
Previous Volunteer Experience: ________________________________________________________________________________
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OTHER INFORMATION
References:
Personal: __________________________________________________________________________________
Name
Phone
Relationship
Business: ___________________________________________________________________________________
Name
Phone
Relationship
Emergency Contact:
Name: __________________________ Relationship_________________ Primary Phone ___________________
Address: ___________________________________________________________________________________
Criminal History:
Within the last seven years, have you ever been convicted of a criminal offense (other than a minor traffic
violation) after your 18th birthday? (Conviction will not necessarily disqualify an applicant; consideration
will be given to the nature and timing of the crime in relation to the position.)
 Yes  No
If yes, please explain: _____________________________________________________________________
Are there any currently pending and/or unresolved criminal charges?  Yes  No
If yes, please explain: _____________________________________________________________________
CONFIDENTIALILTY & COMMITMENT
I hereby agree to abide by the volunteer policies, hospital rules and regulations, and to uphold patient
confidentiality as I fulfill my role as a volunteer. I understand and confirm my willingness fulfill the commitment for
my volunteer assignment within the best of my ability. I certify that the above information is true, accurate and
complete.
APPLICANT SIGNATURE:
Print: ________________________________________________________
Sign: ________________________________________________________
If applicant under 18 years of age:
I understand my child has made a commitment of 6 months to volunteer through Providence Newberg Medical
Center. I give permission for my child to be given a TB test, which is required by state law and provided by
Providence Health & Services.
In the event I cannot be reached, I give permission for necessary emergency treatment to be given to my child in
case of illness or injury.
PARENT/LEGAL GUARDIAN SIGNATURE:
Print Name: __________________________________ Relationship: _______________________
Phone: _________________________________________________________________________________
Address: ________________________________________________________________________________
Signature: ________________________________________________
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ADDITIONAL QUESTIONS
Volunteer applicant name: ______________________________________________________
1. Why do you want to volunteer through one or more of Providence Newberg Medical Center’s Community
Connections programs?
_
2. Why would you make a great volunteer?
3. Describe a few of your personal strengths and personal challenges:
4. What else should we know about you before deciding?
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VOLUNTEER PREFERENCES
Following are examples of the areas where we place volunteers. Placement depends on availability.
Providence Newberg Medical Center Volunteer Opportunities
Ambassador, Clerical/Administrative Projects, Data Entry, Emergency Department, Gift Shop, Intensive Care Unit, Mail
Courier, Medical/Surgical, Oncology, Pet Partners, Surgery Information Desk, Lifeline, Home Health, and Wound Care
Clinic
Community based Volunteer Opportunities
Volunteer Caregivers, Strong for Life Coach, Family Friends Mentor, Kids Day Out, Promotores
Please select your top three areas of interest from opportunities list above:
1. _________________________ 2. _____________________________ 3._________________________
AVAILABILITY
Indicate the days and times you are available to volunteer (check all that apply):
Morning
Afternoon
Evening
Sun
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Mon
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Tue
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Wed
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Thur
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Fri
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Sat
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Tell us about days, weeks or months that you are not available to volunteer:
In addition to your regularly planned commitment, are you open to be asked to assist with special projects on an
“as needed” basis?  Yes  No
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HEALTH QUESTIONNAIRE
It is the policy of Providence Health & Services for each volunteer to have a health questionnaire on file. The health
record is kept in confidence by the department. Should you have any questions, please feel free to ask the Program
Coordinator.
IMMUNIZATIONS & CHILDHOOD DISEASES
Please answer the following questions. Have you had the following diseases?
Yes
No
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Measles (rubeola / hard measles?)
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Mumps
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Rubella (3 day / German measles?)
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Chicken Pox
Have you completed the following immunizations?
Yes
No
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Measles
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Combined measles, mumps, rubella (MMR)
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Diphtheria, tetanus & pertussis (DTaP)
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Flu shot annually?
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Hepatitis B: _______ Year completed: ________
TUBERCULOSIS SCREENING
Yes
No
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Have you had a TB test?
Have you ever had redness or swelling after a TB skin test?
SAFETY AND ACCOMMODATIONS
Please list any medications you are currently taking that may impact your ability to safely perform the functions of
your volunteer position or pose a safety concern.
________________________________________________________________________________
Yes
No
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Are you willing to wear required safety equipment such as gloves and masks on
duty?
Are you allergic to any substances, materials or medications?
If yes, what?
Do you have any illnesses or infectious diseases which may be potentially
transmitted to others in the hospital or health care setting?
Are there accommodations needed to assist you in being able to perform the
essential functions of your job?
Are there accommodations needed for your safety or the safety of others at work?
Are you able to push patients in wheelchairs?
Are you able to walk the distance of the hospital several times a day?
Do you feel comfortable talking with different cultural and ethnic persons?
Can you take direction from staff in various areas of the hospital?
SIGNATURE:
Print:___________________________________________________
Sign:______________________________________________________ Date:________________
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