Select One

Volunteer Type New VolunteerReturning Volunteer

1. Personal Information

First Name

Middle Name

Last Name

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

Email

I certify that I am between the ages of 14 - 17

Have you ever been convicted of a felony? SelectYesNo

Are you authorized to work in the United States YesNo

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex. This application is submitted with understanding that a health assessment, (at Ochsner) must be completed prior to commencing volunteering as a condition to start. I certify that the answers given to the foregoing statements are correct and without omission. I authorize the company to investigate the foregoing; and my former employers from any liability for damage, which may result from any such investigation. If upon investigation, anything contained in this application is found to be untrue, I understand I will be subject to dismissal at any time during the period of volunteering. Your signature indicates your approval for us to check references. The Volunteer Service department is not obligated to provide a placement, nor are you obligated to accept the position offered. I understand that if accepted, I will contribute in excess of 50 hours in a timely manner. I also understand that I will not be paid for my service.

I certify the above is true to the best of my knowledge.

I understand.

I understand that I may receive proprietary, privileged, and/or confidential information in orientation and while volunteering at Ochsner. I will adhere to my responsibilities to maintain confidentiality at all times. I understand that I may receive orientation through an email link and that it is intended for the sole use of me as a volunteer applicant. I will not disseminate, distribute, or copy orientation to anyone else.

2. Where would you like to work?

Location -- Choose oneUndecidedKennerWest BankBaptistBaton RougeNorth ShoreSlidellCovingtonAbitaHammondLeonard J. Chabert Medical CenterSt. Charles Parish HospitalOchsner Medical Center - Jefferson Hwy.Ochsner St. Anne St. Bernard Parish Hospital Ochsner Medical Center - Hancock

Area of Interest SelectPatient CareClerical ServiceServiceOther

If other, please specify

3. Emergency Contact

Emergency Contact Name

Emergency Contact Phone

This form does not encrypt your message and it is not an appropriate means of communicating confidential information. Do not use this form to send personal information, such as account numbers, insurance information or social security numbers. We do not provide medical advice through this form.