Volunteer Application

Select One

Volunteer Type

•   New Volunteer
•   Returning Volunteer

1. Personal Information

First Name*

Middle Name

Last Name*

Address*

City*

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana 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 Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip*

Phone Number*

Email*

I certify that I am 18 years of age or older*

Have you ever been convicted of a felony?* Select Yes No

Are you authorized to work in the United States?* Select Yes No

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?

Facility* Undecided Ochsner Medical Center - Kenner Ochsner Medical Center – West Bank Ochsner Baptist Ochsner Medical Center - Baton Rouge Ochsner Medical Center - North Shore Ochsner's Slidell Clinic Ochsner's Covington Clinic Ochsner's Abita Clinic Ochsner's Hammond Clinic Leonard J Chabert Medical Center St. Charles Parish Hospital Ochsner Medical Center - Jefferson Hwy.

Area of Interest Select Patient Care Clerical Service Service Research Other

If other, please specify:

3. Personal References

References must be a non-relative (friend, peer, co-worker, boss, classmate, neighbor, etc.)

Reference 1 Name*

Reference 1 Email*

Reference 1 Phone*

Reference 1 Address

Reference 2 Name*

Reference 2 Email*

Reference 2 Phone*

Reference 2 Address

4. Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*