Adult Volunteer Application
Are you pursing a degree or career in a healthcare related field?
Yes
No
Please note that the Adult Volunteer Program is not meant for those pursing a degree or career in a healthcare
related field. If you are 18 years or older and pursing a degree or career in a healthcare related field, please
refer to the Student Volunteer Program. Those participating in the Adult Volunteer Program will not receive
hours verification or letters of recommendation for universities, applications, or other programs that require
Emergency Contact Information
Are you related to or friends with a PVHMC employee, physician, or Volunteer?
Yes
No
Why do you want to volunteer at PVHMC?
Have you previously applied for a postition at PVHMC?
Yes
No
Adult Volunteer Service Areas
The Adult Volunteer Program offers a variety of service areas that provide meaningful and fullfilling experiences
for our Volunteers. All of these services are created to add to the experience of our patients and visitors and
give assistance to the Associates of PVHMC. Please see below some of the service areas we offer:
Out-Patient Pavilion Lobby
Out-Patient Pavilion Pre-Op/Post-Op
What days are you available to volunteer? (Check all that apply)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Do you have a known allergy to latex?
No
Yes
Do you have any physical limitations to be considered for volunteer placement?
No
Yes
Do you require any special accommodations?
No
Yes
Background Check Notification
Please answer accurately. We conduct full background checks on all candidates.
Have you ever been convicted of a felony or misdemeanor?
No
Yes
If yes, please give date, place of conviction, and explain circumstances. Please be aware that
a criminal record does not automatically disqualify you from volunteer work at PVHMC.
Whether or not formally charged or convicted, have you ever been arrested for a drug or
No
Yes
If yes, please give date, place of conviction, and explain circumstances.
Please read carefully. Volunteer's certification, agreement and notice.
I certify that all information in this application is true and complete. I understand that
any false information or omission may disqualify me from further consideration for volunteer
service and may result in my dismissal, if discovered at a later date.
I understand that Pomona Valley Hospital Medical Center requires certain information both
personal and professional from me to evaluate my qualifications for volunteer service. I
understand that in review of my application, a background investigation may be conducted.
I authorize and release all past and present employers, personal references and any other
organization to answer all questions asked concerning my previous employment and/or
volunteer record, ability, character, emotional background, military services, criminal and, if
applicable, driving history.
In consideration of my application for volunteer service, I authorize Pomona Valley Hospital
Medical Center and all associated entities, to conduct an investigation which may include, but
is not limited to, the performance of medical examinations, drug screening, reference
verification, driving history, military service, and criminal background check which may be in
the files of any federal, state, or local criminal justice agency. I understand that any
information requested is for the sole purpose of gathering information accurately for use in
the above-mentioned volunteer and background investigation.
job/career training, nor is it meant to lead to paid employment at PVHMC. My services are
donated to the hospital without contemplation of compensation or future employment and
given with humanitarian or charitable reasons.