FIU VOLUNTEER APPLICATION (A)
Herbert Wertheim College of Medicine
VOLUNTEER APPLICATION Form A
Instructions: Please complete this application entirety and submit to EH&S
1. Personal Information:
Name: ___________________________________
Age: [ ] 16 to <18
[ ] 18 and older
Telephone: ________________________________ Cell Phone: _______________________________
Mailing Address: ______________________________________________________________________
City, State, Zip: _______________________________Email: ___________________________________
2. Emergency Contact:
Name: ______________________________________ Relationship: ____________________________
Telephone: ________________________________ Cell Phone: _______________________________
Mailing Address: ______________________________________________________________________
City, State, Zip: _______________________________Email: ___________________________________
3. FIU Department:
Department at which I will be volunteering: _______________________________________________
Major duties: ________________________________________________________________________
___________________________________________________________________________________
Name of Supervisor: __________________________________________________________________
Supervisor’s Telephone: ___________________________ Email: _______________________________
5. Education: [ ] High School (Current Student or Graduate) [ ] College [ ] Graduate
6. Relevant Experience
Work:
Employer: ____________________________________________________________________
Supervisor: ________________________________ Telephone: ________________________
Job Title: __________________________________ Email: _____________________________
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FIU VOLUNTEER APPLICATION (A)
Tasks Performed: _______________________________________________________________
______________________________________________________________________________
Reason for Leaving: _____________________________________________________________
Volunteer:
Name of Organization: ___________________________________________________________
Supervisor: __________________________________ Telephone: ________________________
Tasks Performed: ________________________________________________________________
______________________________________________________________________________
ACKNOWLEDGEMENTS
I am freely and voluntarily offering my services to Florida International University for
(check one):
[ ] Voluntary work - regular-service
[ ] Voluntary work - occasional-service
I will not receive any monetary or material compensation for performing this service.
The University has the right to terminate my volunteer services at any time. In performing said service, I am an
independent, unpaid volunteer not subject to any provisions of law relating to state employment, to any
collective bargaining agreement between the State and any employees' association or union, nor to any laws
relating to hours of work, rates of compensation, leave time, and employee benefits; and in the event of my
termination, I am not entitled to receive unemployment compensation. I understand that while I am
performing the volunteer services, and acting within the scope of my specific assigned duties, I will be covered
by the State of Florida workers' compensation policy and the State liability protection, as appropriate.
As a volunteer, I agree to comply with all Florida International University policies, and the requirements of its
governing board, and all applicable state and federal statutes, rules and regulations, and to fulfill my volunteer
responsibilities to the best of my ability.
I confirm, that the information provided herein and on any attachments is true, accurate, complete, and made
in good faith, and I agree to abide by FIU’s rules and regulations while in its employment.
______________________________________ _________________________
Printed Name of Volunteer
Phone #
______________________________________ _________________________
Signature of Volunteer
Date
Parental /Guardian Assurance if Volunteer is a Minor
I have read and understood the above document.
______________________________________ _________________________
Printed Name of Parent or Legal Guardian
Phone #
______________________________________ _________________________
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FIU VOLUNTEER APPLICATION (A)
Signature of Parent or Legal Guardian
Date
Complete this section if the Volunteer will be in a HWCOM laboratory
Volunteer’s Assurance
I understand the Potential Hazard Information explained by the Principal Investigator describing the potential
risks and dangers associated with my participation in the research project. I agree and understand that my
participation in the research project may be suspended at any time, at the discretion of FIU and its officers,
agents, and employees.
I have read and understood the above document. I will complete and follow safety training specific to the
hazards in the laboratory. I will always wear the personal protective equipment (PPE) as directed and dispose
of it appropriately. I will always remove PPE when leaving the work area. I will always follow the instructions
of the sponsor or laboratory supervisor.
______________________________________ _________________________
Printed Name of Volunteer
Phone #
______________________________________ _________________________
Signature of Volunteer
Date
Parental /Guardian Assurance if Volunteer is a Minor
I understand the Potential Hazard Information explained by the Principal Investigator describing the potential
risks and dangers associated with my child’s participation in research activities and I agree to allow my child
to participate in these activities.
______________________________________ _________________________
Printed Name of Parent or Legal Guardian
Phone #
______________________________________ _________________________
Signature of Parent or Legal Guardian
Date
Principal Investigator Assurance
I agree to sponsor _____________________________ and by my signature agree that:
I will ensure that all of the volunteer‘s required safety training is completed and documented. Personal
protective equipment appropriate for, and specific to, laboratory hazards will be provided. This individual
will be supervised at all times. My laboratory is in full compliance with all applicable FIU safety programs and
regulations.
______________________________________ _________________________
Printed Name of PI
Phone #
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FIU VOLUNTEER APPLICATION (A)
______________________________________ _________________________
Signature of PI
Date
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