KAISER PERMANENTE
CJU
ONTARIO
Kaiser Permanente Medical Center
Complete & Return this form
APPLICATION
Date:
Adult
VOLUNTEER
College Student
High
School Student
NameFirst
_________________________________________________________________________________
Middle
Last
Home Phone
_____________________________________
Street Address ________________________________________________________________________
Cellular
Phone ___________________________________
City, State, Zip ______________________________________________________________E-mail Address
______________________________________________
Are you willing and able to commit 100 hours or 1 year of service to Kaiser Permanente?
Are you willing and able to commit to a regularly scheduled 4 hour shift each week?
Yes -
Yes -
No -
No -
In order to evaluate your application and determine whether we will be able to offer you a place on our team, we
would like to get to know you better. As you answer the questions below, please feel free to attach additional
pages if needed. We also encourage you to send a resume, letter of reference or other documents that might
help support your application.
Please share with us why you would like to volunteer at Kaiser Fontana or Ontario Medical Center:
Please describe for us a time when you have interacted with someone who was ill, recovering from surgery or recovering
from mental illness. What were your challenges and successes?
Do you have previous volunteer experience? If yes, please list locations, positions held and dates for your previous
experience. If no, please share life/work experiences that will help you succeed as a volunteer in a hospital.
What experience do you wish to gain while participating in the Kaiser Permanente Volunteer Program:
What tasks or departments are of interest to you?
Do you have any special skills, talents or interests you would be willing to share with us?
__________________________________________________________________________________________
_______________________________
FOR TEEN VOLUNTEERS: TWO LETTERS OF RECOMMENDATION ARE REQUIRED
TO BE RETURNED WITH THE APPLICATION. LETTERS CAN BE FROM TEACHERS,
COACHES, OR PASTORS.
PLEASE HAND-DELIVER COMPLETED FORM TO:
Kaiser Permanente Ontario Medical
Center
2295 S. Vineyard Avenue
ONTARIO MEDICAL CENTER
VOLUNTEER SERVICES APPLICATION
(PLEASE PRINT IN BLUE OR BLACK INK)
TO THE APPLICANT: KAISER FOUNDATION HEALTH PLAN, INC., KAISER FOUNDATION HOSPITALS (TOGETHER KFHP/H), KFHP/HS SUBSIDIARIES, SOUTHERN CALIFORNIA
PERMANENTE MEDICAL GROUP, AND THE PERMANENTE MEDICAL GROUP, INC. (KAISER PERMANENTE) ARE EQUAL OPPORTUNITY VOLUNTEER ORGANIZATIONS.
KAISER PERMANENTE MAKES VOLUNTEER PLACEMENT DECISIONS BASED ON QUALIFICATIONS ONLY WITHOUT REGARD TO RACE, RELIGION, COLOR, NATIONAL
ORIGIN, ANCESTRY, SEX, AGE, MARITAL STATUS, DISABILITY, MEDICAL CONDITION, SEXUAL ORIENTATION, VETERAN STATUS, OR OTHER NON-JOB RELATED FACTORS
PROHIBITED BY APPLICABLE FEDERAL, STATE, OR LOCAL LAWS. KAISER PERMANENTE PROVIDES APPLICANTS WHO HAVE DISABILITIES WITH REASONABLE
ACCOMMODATION TO ASSIST IN THE INTERVIEW/VOLUNTEERING PROCESS. APPLICANTS REQUIRING ACCOMMODATION SHOULD CONTACT THE VOLUNTEER
DIRECTORS OFFICE. KAISER PERMANENTE IS A SMOKE-FREE WORKPLACE. THIS DOCUMENT MUST BE COMPLETED IN ITS ENTIRETY BEFORE VOLUNTEER PLACEMENT
CAN BE AUTHORIZED.
PERSONAL DATA
NAME (LAST)
ADDRESS (NUMBER)
(FIRST)
(MIDDLE)
(STREET)
(APARTMENT #)
TODAYS DATE
HOME / CELL TELEPHONE
(
CITY
STATE
ZIP CODE
EMAIL
EMERGENCY CONTACT PERSONS (NAMES AND TELEPHONE NUMBERS)
1)
2)
HOW DID YOU HEAR ABOUT THE FMC KAISER PERMANENTE VOLUNTEER SERVICES PROGRAM?
COUNSELOR/TEACHER
FRIEND
SCHOOL CAREER FAIR
PRESENTATION
BROCHURE
KAISER PERMANENTE EMPLOYEE
SYEP WEBSITE
OTHER: __________________________
HAVE YOU EVER BEEN EMPLOYED BY KAISER PERMANENTE OR
ANY OTHER KAISER ORGANIZATION?
YES
NO
IF YES, NAME OF FACILITY OR ORGANIZATION
WHERE
POSITION HELD
WHEN
NAME USED
DO YOU HAVE RELATIVES WORKING FOR KAISER PERMANENTE? IF YES, INDICATE NAME, RELATIONSHIP, DEPARTMENT, LOCATION
YES
NO
WHY DO YOU WANT TO VOLUNTEER?
PERSONAL FULFILLMENT
SCHOOL REQUIREMENT
OTHER: __________________________
COURT ORDERED COMMUNITY SERVICES
REFERENCES
(NON-RELATIVES)
NAME
TELEPHONE NUMBER
HOW DOES THIS PERSON KNOW YOU
OCCUPATION
NAME
TELEPHONE NUMBER
HOW DOES THIS PERSON KNOW YOU
OCCUPATION
EDUCATION INFORMATION
CURRENT SCHOOL NAME
COLLEGE ATTENDED/ATTENDING:
COUNSELORS NAME
GRADE YOU WILL COMPLETE THIS YEAR
EMPLOYMENT & VOLUNTEER EXPERIENCE
LIST CURRENT AND PREVIOUS WORK EXPERIENCE (INCLUDE VOLUNTEER WORK)
COMPANY NAME / ADDRESS / PHONE
DATES EMPLOYED
JOB TITLE AND DUTIES PERFORMED
FROM:
TO:
TITLE:
DUTIES:
FROM:
TO:
TITLE:
DUTIES:
FROM:
TO:
TITLE:
DUTIES:
FROM:
TO:
TITLE:
DUTIES:
LANGUAGE PROFICIENCY (OTHER THAN ENGLISH)
LANGUAGE
READS
AMERICAN SIGN LANGUAGE (SIGN)
WRITES
YES
SPEAKS
NO
SKILLS
CHECK SKILLS THAT YOU POSSESS
TYPING
WORDS PER MINUTE
COMPUTER SKILLS
OTHER
SKILLS
SKILLS, INTERESTS, AND HOBBIES:
NUMBER OF SEMESTERS
TYPE OF SOFTWARE USED (CHECK ALL THAT APPLY)
INDICATE SKILL LEVEL: BEGINNING (B), INTERMEDIATE (I), OR ADVANCED (A)
EXCEL
MICROSOFT WORD
POWERPOINT
ACCESS
ADOBE PHOTOSHOP
DESKTOP PUBLISHING
OTHER
_________________________
ONTARIO MEDICAL CENTER
VOLUNTEER SERVICES APPLICATION CONTINUED
(PLEASE PRINT IN BLUE OR BLACK INK)
REFERENCES
(NON-RELATIVES)
PRINT FULL NAME
LAST
FIRST
MIDDLE
ADDRESS
NUMBER
STREET
CITY
STATE
ZIP CODE
COUNTY
FROM
PRINT FULL NAME
LAST
FIRST
MIDDLE
ADDRESS
NUMBER
STREET
CITY
STATE
ZIP CODE
COUNTY
FROM
PRINT FULL NAME
LAST
TO
FIRST
TO
MIDDLE
ADDRESS
NUMBER
STREET
CITY
STATE
ZIP CODE
COUNTY
FROM
TO
APPLICANT STATEMENT
THIS APPLICATION IS SUBMITTED WITH THE UNDERSTANDING THAT ALL VOLUNTEER PLACEMENTS ARE CONDITIONAL AND WILL NOT BE
CONFIRMED UNTIL SATISFACTORY COMPLETION OF A PRE-VOLUNTEER HEALTH-SCREENING AND BACKGROUND CHECK . I HEREBY CONSENT
TO SUCH REQUIRED SCREENING AND TO THE INCLUSION OF A STATEMENT WHETHER I HAVE PASSED OR FAILED THE SCREENING IN MY
PERSONNEL FILE.
I HEREBY AUTHORIZE KAISER PERMANENTE TO SOLICIT ALL INFORMATION RELEVANT TO THIS APPLICATION. THIS AUTHORIZATION
INCLUDES BUT IS NOT LIMITED TO A CRIMINAL RECORDS CHECK, MY ACADEMIC BACKGROUND, EMPLOYMENT HISTORY AND FEDERAL OR
STATE SANCTIONS/EXCLUSIONS. I AUTHORIZE AND REQUEST ALL PERSONS, SCHOOLS, COMPANIES, CORPORATIONS, GOVERNMENTAL,
LAW ENFORCEMENT, AND OTHER AGENCIES TO RELEASE SUCH REQUESTED INFORMATION TO KAISER PERMANENTE.
I CERTIFY THAT THE ANSWERS I HAVE PROVIDED ABOVE ARE TRUE, CORRECT, AND COMPLETE. I UNDERSTAND ANY FALSIFICATION,
MISREPRESENTATION, OR OMISSION OF FACTS IS SUFFICIENT REASON FOR DISQUALIFICATION FROM FURTHER CONSIDERATION.
I ALSO UNDERSTAND THAT IF I AM A VOLUNTEER AT KAISER PERMANENTE, MY VOLUNTEER STATUS CAN BE TERMINATED AT ANYTIME
WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I UNDERSTAND THAT A COPY OF THIS DOCUMENT IS AVAILABLE TO ME IF I SO
DESIRE.
IF UNDER THE AGE OF 18, PLEASE PROVIDE YOUR BIRTHDATE: _______________________________________.
THE MINIMUM AGE TO VOLUNTEER AT KAISER PERMANENTE HOSPITAL IS FOURTEEN (14) YEAR OLD. BY SIGNING
18.
SIGNATURE: __________________________________________________________________
APPLICANTS SIGNATURE
DATE
PARENTAL CONSENT (IF UNDER 18)
DATE
HERE, I ATTEST THAT I AM UNDER THE AGE OF
