Professional Documents
Culture Documents
CITY_____________________________________________________STATE_______ZIP____________
E-MAIL ADDRESS______________________________________________________________________
Are you a U.S. citizen or, if not, do you have a current alien registration receipt card? _____no ____yes
EMERGENCY CONTACTS:
_______________________________________________________________________________________
(Name and Relationship) (Home Phone) (Work Phone)
_______________________________________________________________________________________
(Nearest Relative) (Home Phone) (Work Phone)
_______________________________________________________________________________________________
(Name of physician) (City) (Phone)
EDUCATION:
____________________________ High School _____________________________College Degree
_______________________________________________________________________________________
Have you ever been convicted of a felony, entered a plea of guilty to a felony charge, entered a plea of
no contest to a felony charge or have you ever had an adjudication withheld?
NO________ YES_______
If yes, please explain:__________________________________________________________________
1. Do you have any physical limitations that would affect your volunteer placement such as bad back, poor
hearing, or poor vision, etc? Yes No
1. Personal references are required for all volunteer files. Reference forms will be provided at the volunteer
orientation.
EMPLOYMENT:
Current or last place of employment ____________________________________________________
Have you ever been discharged or asked to resign by an employer: _____No_____Yes, please explain:
___________________________________________
SPECIAL SKILLS:
___Accounting ___Data Entry ___Mechanical
___Art Work ___Escort/Transport ___Musical (instrument/vocal)
___Bookkeeping ___Filing ___Organizing
___Calligraphy ___Fundraising ___Patient Care
___Carpentry ___Infant/Childcare ___Phone Receptionist
LANGUAGES:
VOLUNTEER AGREEMENT
(Please initial after reading the statements below)
___ As an H. Lee Moffitt Cancer Center volunteer I agree to uphold the values of the organization by
providing a high standard of quality service to our patients and staff.
___ I agree to hold, absolutely confidential, all information that I may obtain directly or indirectly
concerning patients, doctors, or personnel.
___ I can be depended on to work my assigned shift and will call, in advance, if not able to fulfill that
obligation.
___ I will wear the proper uniform as outlined in the orientation packet.
___ I understand that I will be expected, before placement, to complete the Volunteer Training Program
and required TB screening.
Signature:_____________________________________ Date:________________________________
YOUR SIGNATURE INDICATES YOUR APPROVAL FOR US TO CHECK REFERENCES AND CONTACT YOUR PHYSICIAN REGARDING YOUR
PHYSICAL AND EMOTIONAL HEALTH. THE ORGANIZATION IS NOT OBLIGATED TO PROVIDE A PLACEMENT, NOR ARE YOU OBLIGATED TO
ACCEPT THE POSITION OFFERED. A VOLUNTEER POSITION DOES NOT CONSTITUTE AN EMPLOYEE-EMPLOYER RELATIONSHIP WITH THE
CANCER CENTER.
OPPORTUNITIES FOR VOLUNTEERS ARE PROVIDED WITHOUT REGARD TO COLOR, RACE, RELIGION, AGE, CREED, NATIONAL ORIGIN, SEX,
DISABILITY, VETERAN OR MARITAL STATUS. H. LEE MOFFITT CANCER CENTER REASONABLY ACCOMMODATES INDIVIDUALS WITH
DISABILITIES.
I understand that the reason for this minimum commitment is due to considerable
hospital resources dedicated to the volunteer on-boarding process. This process
includes screening, background checks, TB/health screening, photo ID badge,
orientation, screening, training, placing, training, and supervising volunteers. This is
provided at no cost to me.
The dependability of volunteers directly impacts the quality of service provided to the
patients. Students who are reliable will be invited to participate in unique patient care
areas.
With this in mind, I have considered my obligations to school, work, and other extra-
curricular activities. If accepted as a volunteer at Moffitt Cancer Center, I pledge to
contribute three to four hours per week for two semesters.
I hereby authorize H. Lee Moffitt Cancer Center & Research Institute, and its designated agents and representatives to
conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be
generated for volunteer purposes.
I understand that the scope of the consumer report/investigative consumer report may include, but is not
limited to the following areas:
Verification of social security number; current and previous residences; employment history including all
personal files; education; character references; credit history and reports; criminal history records from any
criminal justice agency in any or all federal, state, county jurisdictions; birth records; motor vehicle records to
include traffic citations and registration; and any other public records.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration
and law enforcement agencies) to divulge any and all information, written or verbal, pertaining to me to H. Lee Moffitt
Cancer Center & Research Institute or its agents. I further authorize the complete release of any records or data pertaining to
me which the individual, company, firm, corporation, or public agency may have, to include information or dates received
from other sources.
I hereby release H. Lee Moffitt Cancer Center & Research Institute, the Social Security Administration, and its agents,
officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and
collectively, from any and all liability for damages of whatever kind, which may, at any time result to me, my heirs, family, or
associates, because of compliance with this authorization and request to release. You may contact me as indicated below.
I understand this authorization automatically expires 90 days from the date executed below and that I have the right to revoke
the authorization at anytime, provided I do so in writing.
Please print clearly.
Name:_____________________________________________________________________________________________________
(Last) (First) (Middle) (Maiden)
Please check all that apply: ( ) Vietnam Era Veteran ( ) Disabled Veteran
( ) Disabled Individual (indicate type of disability): __________________________________
( ) Visual ( ) Hearing ( ) Chronic Illness ( ) Mobility ( ) Other
Please list all home addresses that you have had in the last five years:
Current ___________________________________________________________________________________________________
(Since:Mo/Yr) (Street) (City) (Country) (State) (Zip)
Previous __________________________________________________________________________________________________
(Since:Mo/Yr) (Street) (City) (Country) (State) (Zip)
Previous __________________________________________________________________________________________________
(Since:Mo/ Yr) (Street) (City) (Country) (State) (Zip)