Volunteer Application Contact information: 406.823.6256 Complete the form below and we will contact you. First Name Middle Name Last Name Present Street Address Present Street Address Line 2 City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming ZipCode Phone Number Cell Phone Number Email Address Are you 18 years old or above? YesNo When are you available to start volunteering? Are you available to work at least one 4 hour shift once a week? YesNo Times you are available to volunteer: MTWTHFMorningsAfternoons What does volunteering mean to you? Why are you interested in volunteering with Livingston HealthCare? Have you volunteered in a health care setting before? YesNo *If yes, please describe your experience: Describe any specialized skills, training, or extra-curricular activities: Previous work/Volunteer experience: Name of Organization: Dates worked/volunteered: Job duties: Name of Organization Dates worked/volunteered: Job duties: Personal or professional references Reference Name: Relationship to applicant: Reference Phone: Reference Name: Relationship to applicant: Reference Phone: Please indicate your preferences in providing services: Patient transport to and from the parking area/other locations YesNo Answering phones YesNo Friendly Visits YesNo Assisting patients and visitors with way finding throughout facility YesNo Stocking medical and administrative supplies YesNo Event coordination and assistance YesNo Landscaping, weeding, trail maintenance YesNo Reading to patients or offering reading materials to unit YesNo No patient contact, i.e. typing, filing, administrative duties YesNo Assisting patient families YesNo Other (If yes, please explain below) YesNo *If other, please explain: CRIMINAL RECORD INFORMATION: Have you ever pled guilty or been convicted of a crime other than a minor traffic violation? (A conviction record will not necessarily disqualify you from volunteering.) YesNo *If yes, give conviction date, crime convicted of, law enforcement agency, court jurisdition, disposition, and type(s) of rehabilitation, if applicable: I understand that in accepting this application, Livingston HealthCare is in no way obligated to provide me with a volunteer position and that I am not obligated to accept volunteer position if offered. I understand that none of the documents, procedures, actions, statements of Livingston HealthCare or its representatives used during the volunteer process is deemed a contract of a volunteer position, real or implied. I authorize investigation of all statements contained in this application for a volunteer position as may be necessary in arriving at a volunteer decision. Livingston HealthCare is a drug-free workplace. Livingston HealthCare does not accommodate the medical use of marijuana in the workplace, which is in accordance with Montana Code I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application, or omission of fact on either this application or during the pre-volunteer process, may result in my application being rejected, or, if I am accepted, my volunteering could be terminated. I understand, also, that I am required to abide by all rules and regulations of the organization. I also understand that any volunteer opportunity made to me by Livingston HealthCare is conditional on satisfactory completion/fulfillment of all pre-volunteer requirements (e.g., PPD “TB” testing, criminal background checks, etc.). By checking the box below, I agree to the terms stated above. I agree Disclosure Regarding Background Investigation Livingston HealthCare (“the Company”) may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report is an employment history or verification. These searches will be conducted by SimpliVerified, 12441 South 900 East #220, Draper, UT,84020, 1-855-837-1328, www.simpliverified.com. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law. By checking the box below, I agree to the terms stated above. I agree Submit My Information