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

Medical Arts Building
P.O. Box 147006
Gainesville, FL 32614-7006
(352) 333-4585 office
(352) 333-4538 fax
Thank you for your interest in the Volunteer Program at North Florida Regional Medical Center. It
is important that you read the instructions carefully as incomplete applications will be returned. To be
eligible for our program you must be able to:
•
•
•
Commit to a regular weekly schedule. Volunteer Services is not able to change your schedule
if you have a fluctuating school and/or work schedule. You must be able to commit to the
same day and the same time each week.
Commit to at least 2 – 4 hours each week.
Understand that this is a volunteer program only. We do not offer shadowing or internships
here.
If you can meet the above requirements, please complete the onboarding components listed below.
Please complete STEP 1 and mail your packet to: NFRMC, Volunteer Services, P.O. Box 147006,
Gainesville, FL 32614-7006. If you wish to turn in your application in person, please call the office
at (352) 333-4585 to make an appointment. Please note that the Volunteer Department is not
located in the hospital.
STEP 1
• Volunteer Application: Complete the enclosed application, sign and date.
• Volunteer Resources Skills Questionnaire. Complete the form.
• Disclosure & Release of Information Authorization. Complete form, sign and date.
• Handbook. Read the handbook and answer the questions on the Handbook
Acknowledgement Form, sign and date the form.
• Immunization Records: You are required to provide written documentation that you have
had a MMR (measles, mumps and rubella) vaccine if you were born on or after, January 1,
1957.
• Standards of Performance. Read the document, sign and date the form.
• Confidentiality and Security Agreement. Read the document, sign and date the form.
STEP 2
•
•
You will be notified if your application is accepted. Please note that not all applications
are accepted.
Once accepted, North Florida Regional will request a FDLE (Florida Department of Law
Enforcement) background check. It takes approximately 3 – 5 business days to receive this
report back.
STEP 3
Once you have cleared the background check Volunteer Services will coordinate completion of:
•
•
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PPD (Purified Protein Derivative) testing which is a screen for TB (tuberculosis)
Flu vaccination (Between November – March)
Orientation
Thank you and please contact the Volunteer Services Department at (352) 333-4585 if you have any
questions.
Sincerely,
Susan Walker
Director of Volunteer Services & H2U
Enclosures
2-
North Florida Regional Medical Center
Medical Arts Building
6400 Newberry Road, Suite 110
Gainesville, FL 32614-70006
(352) 333-4585 office
(352) 333-4538 fax
Contact Information:
VOLUNTEER APPLICATION
_______
Last Name
Address
(____)___________
Home Phone Number
First Name
“Nickname”
_
__
____
_______
Apt. No.
City/State
Zip Code
(_____)____________
_________________________________
Cell Phone Number
email address
Emergency Contact Information:
In case of an emergency notify:
_____________________
___________________
Last Name
First Name
(____)________
Phone Number
________________
Relation
Education and Volunteer Experience:
Check all that apply:
 SFC student  UF student  Adult  Senior  Other:______________________________
Students list your degree program or area of study:
_____ _______________________
Past Volunteer Experience:
______
____________________
____
Employment:
_________________
 Currently working but able to volunteer  Not Employed
Availability and Area of Interest:
 Women’s Center Liaison
 Clerical/Office
 Surgery Waiting Room Liaison
 Patient Ambassador
 Other:________________________
Preferred Days:
 Intensive Care Liaison
 Wheelchair Management
Preferred Times (Please be specific):
 Monday
 Morning______
 Afternoon______
 Tuesday
 Morning______
 Afternoon______
 Wednesday
 Morning______
 Afternoon______
 Thursday
 Morning______
 Afternoon______
 Friday
 Morning______
 Afternoon______
 Saturday
 Morning______
 Afternoon______
 Sunday
 Morning______
 Afternoon______
Note: Volunteers can’t volunteer after 9:00 p.m.







Evening______
Evening______
Evening______
Evening______
Evening______
Evening______
Evening______
How long do you anticipate services as a NFRMC volunteer?
 Continue Year Round
 One semester: List Dates:____________
 Other ____________
 Yes
 No
Residency/Security: Are you a resident of the United States?
Your response to any of these security questions will not automatically disqualify you from
volunteering.
Have you ever been convicted (pleaded guilty or been found guilty) of a misdemeanor or felony? List
any and all convictions and provide dates of each (including but not limited to, major traffic
violations, writing bad checks and DWI). However, if you answer “no” and a criminal history is
found or if you answer “yes” but did not include all convictions you will be disqualified from
consideration.
 Yes
 No
______________________________________________________________________________
______________________________________________________________________________
Volunteer Conditions:
I certify that the information on this application is true and complete to the best of my knowledge.
Acceptance into the Volunteer Program at North Florida Regional is contingent upon satisfactory completion of all preplacement procedures which include, but may not be limited to, an interview, criminal background investigation,
orientation and tuberculosis screening.
I understand that any misrepresentation or omission of facts on this application will be sufficient cause for
disqualification of this application. In addition, after obtaining a Volunteer position it is found that the information on
this application is significantly untrue, incomplete or misrepresented; I understand this will result in immediate
dismissal from further participation as a NFRMC Volunteer.
I understand that a volunteer at North Florida Regional Medical Center is minimally required to work a minimum of
two hours per week.
I donate my services without monetary compensation.
I will abide by all the rules and policies of the Volunteer Services Department/North Florida Regional Medical Center. I
will complete health office requirements, necessary training, orientation, observe the dress code, code of ethics, and keep
all patient information confidential.
I understand North Florida Regional Medical Center reserves the right to terminate my volunteer status as a result of
failure to comply with health system; absences without proper notification; unsatisfactory attitude, work, or appearance;
or any other circumstances which, in the department director’s judgment, would make continued volunteer service
contrary to North Florida Regional Medical Center’s best interests.
I have read each of the above conditions, and agree to honor them. In addition, I hereby authorize any prior employers
to provide such information concerning my employment with them as may be requested by NFRMC. NFRMC is an
Equal Opportunity work place and does not discriminate based on age, religion, gender, ethnic background or sexual orientation.
______________________________________
Volunteer Signature
______________________________________
Volunteer Print Name
______________________________________
Volunteer Coordinator’s Signature
Volunteer Application/2.25.15
__________________
Date
__________________
Date