Volunteer Services Department
Fall 2015 University & High School Student Volunteer Information
Thank you for your interest in our volunteer program. We are seeking highly motivated and self-driven
individuals who enjoy a challenge. WEEKLY ATTENDANCE is expected of every student volunteer. If
you have academic responsibilities that will prevent you from attending your 2 or 3 hr shift each week,
you should not apply. This is a major commitment involving more than building a resume’ - you are
building valuable experience – and making a difference in our patients’ lives. Students must meet all
eligibility requirements to become an active volunteer at Presence Covenant Medical Center.
Program Dates: Saturday, Aug. 29 – Dec. 9, 2015
Application Timetable: Application packets will be available June 15 and completed applications
will be accepted through Friday, July 31st at 4 pm. (CDT). Applications need to be submitted
electronically to PCMCVolunteer@PresenceHealth.org.
Interviews:
 Requests for interview appointments will be taken starting once you have submitted an application.
 We will conduct interviews between August 3-14.
Program Eligibility:
 All volunteer candidates must meet all program requirements listed on page 12 of the packet.
 ALL volunteer candidates must be a minimum of 15 yrs of age by June 1, 2015 and in their Jr or Sr.
year of high school. Students that are 15 – 17 years of age are required to have parental
approval/signature to volunteer.
 ALL volunteers must complete the mandatory orientation program. After admission to the fall
program, each candidate will be electronically sent a training packet. The candidate will
complete the study guide independently no later than Aug. 24th and schedule to take the
Orientation Competency Exam on Wednesday, August 26th between the hours of 4 pm – 6pm
 Every applicant must be able to provide Social Security # at the time of interview to complete
the information necessary to conduct a background check and to volunteer.
 Additional training program schedules are listed at the top of page 2 of this packet
 Each candidate must provide three references. (forms included in packet)
 Students will be scheduled ONLY after submitting all required documentation. Applications
may be turned in separately from health records and reference forms.
Health Requirements:




Candidates must show proof of immunity against Rubella and Rubeola (measles) and Chicken Pox.
Each volunteer is required to have a current "2-Step" TB test (2 injections) within the last 3
months. The two (2) injections and two (2) readings must be COMPLETED 7 – 20 days apart.
Single step TB tests are not acceptable. This process takes a minimum of 9 days to complete.
All health requirements must be completed and submitted into our office by July 31st at 4pm.
If you do not submit the required health documentation you will not be eligible to volunteer.
This information should be submitted with the application form and the completed health survey.
IMPORTANT NOTE:
All interviews will be conducted at the County Plaza Building located at 102 E. Main Street in
downtown Urbana located north of the Champaign County Courthouse UNLESS otherwise stated.
Carefully review the full contents of this 12 page packet and be aware of all program requirements
before submitting an application. Exceptions cannot be made for volunteer candidates regarding
orientation, health requirements, background check or weekly attendance.
Page 1
FALL Session 2015 Program Training Requirements
Mandatory Testing Session for ALL volunteers:
Wednesday, August 26th between 4 – 6 p.m.
Presence Covenant Auditoriums A, B & C
All Mandatory Departmental Training Programs
Emergency Department Volunteers
3/Cardiac Services, 3/Maternal Child/Rehab/ Critical Care Unit
Medical/Surgical Units 6, 7 & 8
Patient Transport Services
2015/2016 High School & University Student Program Dates
Fall Semester 2015
Program Dates: Sat., Aug. 29 – Wed., Dec. 9, 2015
Labor Day Holiday: Monday, Sept. 7, 2015 Fall Break: Nov. 21 –29, 2015
Application Deadline: Friday, July 31, 2015 at 4 p.m.
Orientation Testing: Wednesday, Aug. 26, 2015, 4 – 6 p.m.
Auxiliary Auditoriums A, B & C
Spring Semester 2016
Program Dates: Sat, Jan. 23 – Wed., May 5, 2016
Spring Break: Mar. 19 - 27, 2016
Application Deadline: Friday, November 20, 2015
Orientation Testing: Monday, January 18, 2016
Auxiliary Auditoriums A, B & C
Summer Semester 2016
Program Dates: Sat., June 4- Thurs., Aug. 3, 2016
Holiday: Monday, July 4th
Application Deadline: Friday, April 29, 2016
Orientation Testing: Friday, June 3, 2016, 9 – 12 noon
Auxiliary Auditoriums A, B & C
QUESTIONS?
Call Volunteer Services - 337-2378 Office hours: Mon-Fri, 8 a.m. - 4:30 p.m. (excluding holidays)
E-mail at: pcmcvolunteer@PresenceHealth.org
Volunteer Services Offices are located at 102 E. Main, downtown Urbana
Page 2
Presence Covenant Volunteer Services
Non-Clinical Opportunities
Center for Healthy Living Social and Wellness Programs
The Center for Healthy Living provides programs that promote healthy living, reduce the risk of disease and preserve
independence. Volunteer opportunities include help with hosting events. Times and days vary depending on the event and the
volunteer availability. See list of programs and days/times below. Duties include setting the room up, making coffee, setting out
refreshments, greeting and making people feel welcome, and clean up. Volunteer shift would start 30 before to 30 min after event.
Live and Learn Series: This series provides an opportunity to get out and enjoy the company of others and learn something new.
Coffee Shop is every 1st and 3rd Wednesday of the month from 8 -10 am
Lunch and Learn is on the 2nd Wednesday of the month from 11:20am-1:30pm
High Tea is on the 4th Wednesday of each month from 2 – 4 pm
Powerful Living Series: Monthly education event designed to encourage the prevention of disease, as well as educate those who
are recently retired, or soon to retire on topics relevant to them. This program is on the 3rd Tuesday of every month from 6-7:30pm
Bingo: 4th Friday of every month from 2- 4 pm
Potluck and Bingo: 1st Monday of the month from Noon-2:30pm
Luncheons: Lunch and entertainment on a quarterly basis, dates vary and time is from 11 am-1 pm
Central Communications – Volunteers needed to answer patient calls for service
The Central Communications Department is looking for volunteers to assist responding to patient Call Lights during the early
morning shifts. Skills needed to qualify include the ability to answer call lights in a friendly voice and to use a touch screen PC to
send patient requests. This is a very user-friendly system! Training will be provided. Volunteer shifts would be any day, M – F
from 7 – 9 a.m. Volunteer opportunity involves primarily sitting at a work station.
Faith In Action Program (FIA offices are located at the County Plaza building, downtown Urbana)
 Faith in Action Office Assistance
Volunteers are needed to assist in making calls to schedule volunteers to provide service to older care recipients in the program.
Pleasant personality is a must! Some assistance with special events may be needed. This is a wonderful working environment
with great support from staff. Volunteers can provide support any day M – F during 8-4:30 office hours in 2 – 4 hour shifts.
 Faith in Action Care Recipient Volunteers –
The Faith in Action program offers assistance to seniors in the Champaign/Urbana Community. Types of assistance include but
are not limited to transportation, yard work, home visiting for the isolated. Hours are flexible, M-F with some possible weekends
Home Health Medical Records Division
The Presence Home Health Department, Medical Records Division is looking for volunteers to assist with filing,
advance directive follow-up letters and/ or phone calls. Skill needed to quality include the ability to use a computer, a
friendly voice and personality, highly organized, detail orientated, the ability to maintain confidentiality, able to reach
above head to pull charts, and the ability to stand for periods of time. Training will be provided. Volunteers can
provide support on Monday and Friday from 8:30 a.m-12pm or 1pm -4 pm year around.
Out-Patient Pharmacy Assistant (Must have Pharmacy Tech license)
Volunteers for these positions require retail experience and ability to work a cash register. Volunteers are asked to work one shift
any day M – F from either 8:30 – 12:30 or 1 – 5 p.m. Volunteers take prescription orders and assist customers with check out.
Presence Regional EMS/PRO Ambulance Office Assistant
This office is offsite at 408 S. Neil St., Champaign. Volunteers are needed primarily for data entry work. There is a lot of
information weekly that needs to be compiled into various spreadsheets. This position provides a great opportunity to work in a
fast paced environment in the PRO Ambulance base headquarters. Our friendly staff will appreciate your efforts! Training will be
provided for each volunteer. Hours are flexible, Monday – Friday.
Receiving Dock
Volunteers will help staff deliver supplies to floors and get signatures when they are received. Volunteers need to have
organizational skills, friendly personality, and the ability to push a cart of supplies weighing no more than 50LBS. This position
requires a lot of walking and the dock can be cool so one would need to wear layers. Generally, hours would be during regular
business hours Monday- Friday 9 a.m.-2:00 p.m.
Page 3
Presence Covenant Volunteer Services
Clinical Volunteer Opportunities
Ambulatory Surgery
Volunteers will be assisting with patients who are having same day surgery. Duties will be varied including securing patient
belongings in lockers, providing nourishments for patients after surgery, transporting patients to x-ray, delivering patient
belongings to their room and escorting patients to front lobby at time of discharge, and preparing patient area for next patient.
Volunteers will also assist with making up chart packets. Volunteers will be scheduled Monday - Friday. 8 a.m. – 5 p.m.
Cardiac Catheterization Lab
Volunteers provide a variety of clerical as well as patient support services in the busy Cardiac Cath Lab. Duties include:
 Answering telephones
 Transporting patients via cart with a staff member
 Cleaning room between cases
 Restocking disposable supplies
 Assisting with inventory
 Assisting patients during pre and post procedure activities such as applying EKG patches, blood pressure, obtaining pulse, etc.
Volunteers are needed Monday – Thursday between 7 a.m. – 3:30 p.m.
Clinical In-Patient Service opportunities: Please select from 5 department choices below
 Cardiac Services
Cardiac patients will benefit from your care, concern and assistance with basic patient care responsibilities. You have many of the
same responsibilities as with Medical-Surgical units, but these patients are recovering from cardiac events. Volunteers assist with
safety audits on the unit. Volunteers will assist with Patient Satisfaction rounds and assist patients with accessing their Patient
Portal account. Hours available are M – F 9 am.-noon and 1 – 4 p.m., Sa 9 – 12 or 1 – 4 pm, Su 1 – 4 or 4 – 8 pm.
 Medical/Surgical (6E, 7E or 8E)
Volunteers will have the opportunity to work directly with patients and provide services in a variety of ways. Duties include
passing and collecting patient meal trays and documenting output, assist with feeding patients, filling water pitchers, making
occupied beds, delivering flowers, sitting with patients as friendly visitor, Patient Satisfaction rounds and assist patients in
accessing their patient portal account, transport patients within hospital and for discharge and other duties. Volunteers assist with
safety audits on the unit. Hours available are M – F 9 am – noon and 1 – 4 p, Sa 9 – 12 or 1 – 4, Su 1 – 4 or 4 – 8 pm.
 Critical Care Unit
Critical Care Unit patients have a very high acuity and require close monitoring and care. You will assist staff by providing a
variety of services including patient safety audits, answering phones, responding to patient call lights and stocking inventory and
supplies. Volunteers are needed any day Mon – Sun from 9 a.m. – noon or 1 – 4 p.m.
 Rehab Patient Care
Volunteers will provide care for patients who have experienced head, neck, or spinal cord injury or suffered a stroke or other
debilitating illness. Duties include filling water mugs, answering telephones, straightening bulletin boards, delivering meal trays,
helping patients complete menu selections, assembling chart packets, visit patients and many other duties to assist with our
patients. Hours available are Monday - Sunday from 4 – 7 p.m.
Page 4
Presence Covenant Volunteer Services
Clinical Volunteer Opportunities (Cont.)
 Maternal Child Health Services
Volunteers will assist staff in the Postpartum Care and Labor and Delivery unit with basic unit support including stocking supplies,
patient transport at discharge, and unit audits. Expect minimal patient interaction. Volunteer shifts are 11 – 2, 2 – 4:30 or 4:30 – 7
pm M – F.
Community Fitness Program
Volunteer assist staff as exercise assistants by taking heart rates, blood pressures, oxygen saturation readings, adjusting workloads
on the exercise equipment, performing small tasks such as filing charts, putting supplies away, making up “new start” packets, etc.
If you have an outgoing personality and a willingness to interact with patients this placement is for you.
Cardiac Rehab hours are scheduled from 6 – 8 a.m. or 4 – 6 p.m. Monday, Wednesday or Friday, 9:30 am – 12 pm T & Th.
Dietetic Services
Students who are in their junior or senior year in Food & Nutrition or Dietetic studies are eligible to volunteer in Presence
Covenant’s Dietetic Department. Students are assigned a variety of projects working in the office as well as with patients.
Schedules vary but typically involve a 3-hour shift mornings (preferred) or afternoons Mondays – Fridays.
Emergency Services Department (College students and older)
Tasks will include stocking supplies, cleaning, preparing treatment rooms for patients, running errands to lab and other areas,
transporting supplies and specimens. Volunteers will regularly check with patients/visitors in the waiting room and forward
questions/concerns to the ED Charge Nurse. Volunteers transport patients and stay with patients and provide support and other
duties as assigned. Volunteers work under direction of the Charge Nurse. Hours: 6 a.m. – 12 midnight in 3-hour shifts, M – Su.
Emergency Services Department Welcome Center
This volunteer opportunity is perfect for those persons interested in a customer service focus over a patient care focus. Volunteers
will meet and greet patients and visitors as they present at the Emergency Department, answer phones, direct calls, direct patients
and visitors and assist with minor clerical duties assembling patient charts. Volunteers are needed Mon – Sun from 7 – 11 a.m.
Mammography Center
Female volunteers are needed to assist with answering the telephone, escorting patients to and from the mammography area from
the front lobby, making copies of insurance information and assist with small patient mailings. Available shifts are 8 – 11:30 or
11:30 a.m. -3:30 p.m. Mon and Wed and 8 – 12 on Tues and Thurs.
Maternal Child Services Welcome Center
Volunteers are needed in Maternal Child Services to greet and welcome patients and visitors to the unit. Volunteers will escort
visitors and patients into one of the 3 secure areas of the unit ensuring their safe arrival. Volunteers need to be friendly and willing
to move about the unit as required.
Hours available are Monday-Sunday from 8 a.m. – 12, 12 – 4 p.m., or 4 – 8 p.m.
Occupational Therapy (limited availability to college OT/PT majors)
Volunteers provide assistance during occupational therapy sessions with patients in the rehab program. Occupational Therapy
staff supervises volunteers. Occupational Therapy is designed to enable the patient to adjust to living and coping with physical
limitations in their environment. This program offers an excellent opportunity for students pursuing a degree in Occupational or
Physical Therapy. Hours scheduled are 8:30 – 11:30 a.m., or 1 – 3:30 p.m. any one shift, Monday – Friday
Operating Room Department Delivery Clerk (limited to college students & older)
Volunteers who take pride in being self driven and possessing a “can do” attitude are needed to provide assistance in making
delivery of supplies to and from the OR to Central Supply. Volunteer will work in environment with fast paced clinical specialists
with timely needs for supplies. This is a unique opportunity for a volunteer to learn more about how a busy OR functions.
Volunteers will be required to wear scrubs (provided) while working. Shifts needed are Monday – Friday, 8 – 10:30 a.m., and
10:30 a.m. – 1 p.m. or 1 – 3 p.m. One volunteer will be assigned per shift.
Page 5
Presence Covenant Volunteer Services
Clinical Volunteer opportunities (Cont.)
Patient Transporters & Patient Registration Discharge Escorts
Volunteers are needed to provide wheelchair transport services to patients in the front lobby area, throughout the hospital and with
patient discharges. Hours available: M – F, Mornings/Afternoons & Early Evenings, Sat & Sun, Mornings or Afternoons
Patient Newspaper Delivery (Weekends Only)
Volunteers are needed daily to deliver complimentary newspapers to our patients. Volunteers can arrive between 8 – 10 a.m.
Papers are delivered to the patients in all in-patient care areas and waiting rooms. Total delivery time is 1 – 2 hours.
Dependability is a must! This volunteer assignment offers a great opportunity to greet our patients and their family members.
Hours available are Saturday or Sunday between 8 – 11 a.m.
Physical Therapy (limited availability to college OT/PT majors)
Pre-Physical Therapy students or students planning to enter a Physical Therapy program are placed in the Physical Therapy
program. Guidance and supervision is provided by staff physical therapists providing experience with patients of all ages suffering
from permanent or temporary injury from head or neck injury, stroke, automobile accidents and patients who suffer pain and
dysfunction due to join or muscular problems. This experience will be mainly observational with some hands-on experience as
appropriate. Hours scheduled are 8:30 – 11: 30 a.m. or 1 – 3:30 p.m. any one shift, Monday – Friday.
Procedure Center
Volunteers are needed to provide assistance for a variety of duties in the Endoscopy/Procedure Center. This is a busy clinical
diagnostic department where volunteers will be interacting with patients, clinical staff and physicians. Delivering excellent
customer service and patient care is our goal and each volunteer is expected to help us reach that goal!
Volunteers will assemble chart packets, sticker/label charts with patient name for current day patients, clean carts and monitors
between patients, wipe down counter tops and phones, move empty carts from recovery area to admit area, restock patient admit
rooms with supplies, take specimens to the lab, deliver drinks/nourishments to patients in recover area, bring family member(s) to
patient admit rooms or recover areas, round on patients and families to see if they need anything, keep family members/patients
informed while in waiting room, discharge pat6ients via wheelchair and help them into vehicle, and simple departmental audits.
Hours available are Monday –Thursday, 8 a.m. – 11 noon or 11 a.m. – 1:30 p.m. , Friday 8- 11 a.m. or 2 p.m.- 5p.m. (Monday,
Wednesdays and Fridays are priority)
Recreational Therapy
Volunteers work with the staff recreational therapist to provide individual and group recreation programs for our rehab patients.
This program offers a great opportunity to get to know the patients on an individual basis and assist with great programming.
Hours available are: T, W or Th 2:00-5:00 or 4:30 – 7:30 pm
CAREFULLY READ THE ENTIRE APPLICATION PACKET PRIOR TO
FILLING OUT AN APPLICATION FORM TO MAKE SURE YOU MEET
THE APPLICATION ELIGIBILITY REQUIREMENTS.
Page 6
________________________________________________________________________________________________________
Student Volunteer Application Please type or print
Please indicate which ministry you would like to volunteer with by circling one of the following:
PCMC PUSMC
Gender Male Female
Name ______________________________________________________________________________________
Last
First
Middle Name
Local Address____________________________________ Apt.#_________ City___________ State________ Zip__________________
Street
Permanent Address (if different from above)
Address____________________________________ Apt.#_________ City_____________State_____________ Zip_________________
Street
Birth Date______/_______/_______
(Year optional)
Daytime Phone_______________________
Cell Phone__________________________
Email____________________________________________
Last Year of School Completed _____ High School _____College _____Grad School Degree Obtained _________________________
Please state what you would like to get out of this volunteer experience.
___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Do you have any physical limitations which prevent you from doing certain types of tasks?  Yes  No
If yes, please explain: _________________________________________________________________________________________________
Previous Work, Volunteer and Community service experience
Organization
Position Held
Date of Experience
Please provide three (3) professional references (former employers, pastors, etc.)
Name
Address
Email
How many hours each week do you wish to volunteer? _______________________
Which shifts do you wish to volunteer?
Monday___a.m___p.m. Tuesday___a.m___p.m. Wednesday ___a.m___p.m. Thursday ___a.m___p.m. Friday___a.m___p.m. Sat. ___a.m___p.m Sun. ___a.m___p.m
Assignments: Please indicate areas or departments that you are willing to be assigned.
1________________________________ 2______________________________________
1400 West Park Street,
Urbana, IL 61801
217.337.2378
3____________________________________
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false
or misleading representations or omissions may disqualify me from further consideration for a volunteer position and may result in discharge even if
discovered at a later date. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named
in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding a volunteer
decision and I release all such persons from any liability regarding the provision or use of such information.
Signature_________________________________________________________________
Page 7
Date_______________________
Presence Covenant Medical Center
Volunteer Services
Volunteer Applicant Health Survey
Name___________________________________________________________________
Last
First
Phone______________________
M.I.
Address____________________________________ Apt #____________ City___________ State_____ Zip____________
Email Address_________________________________________________
Gender
Male
Female
Emergency Contact_____________________________________________________________________________________
Name
Phone
Relationship
Your Physician______________________________ Clinic___________________________ Phone____________________
Do you now have or have you ever had Chickenpox?  Yes
 No
Have you ever had a positive reaction to a T.B. test?  Yes
 No
List any known allergies to food, medications, and/or environmental substances:______________________________________
Have you had a tetanus shot in the last 10 years?
 Yes
 No
Do you have any health conditions/restrictions you feel we should be aware of?_______________________________________
I understand that physician’s approval may be required for my participation in the volunteer program at Provena Covenant.
Applicant Signature_____________________________________________________________________Date______________
Parent/Guardian signature for student under 18 years of age:
Parent/Guardian Signature_______________________________________________________________Date______________
Illinois State Police Background Check Information
Then following information will be given to the Illinois State Police Department to conduct a background check on the volunteer applicant.
Please fill out all fields.
Name________________________________________________________________________
Last
Gender
First
Male
Female
Birth Date____/_____/____
M.I.
Race_________________________________
Valid codes for Race
White…………………….W
Black……………………..B
Asian/Pacific Islands……A
American Indian/Alaskan. I
Unknown…………………U
Subject Signature: ______________________________________________________________________________________________If you
have any questions, please contact the Illinois State Police Department, Division of Administration, Bureau of Identification, 260
N. Chicago Street, Joliet, IL, 60432-4075
Page 8
Date________________________
Dear, _______________________
____________________________ has applied for a volunteer position at Presence Covenant Medical Center. To meet
accreditation requirements, we are requesting your input or feedback regarding your knowledge of the applicant’s strengths and
skills. We have requested information in short-answer format for your convenience, but you are welcome to provide additional
comments. Acceptance of being a volunteer at Presence Covenant Medical Center is contingent upon completion and return of
this form. Please fax or mail to: Mindy Slack, Volunteer Services, Presence Covenant Medical Center, 1400 W. Park Street,
Urbana, Illinois 61801 Fax: 217-337-4709. You may also scan completed form and e-mail to:
pcmcvolunteer@presencehealth.org. Thank you for your assistance in providing for this volunteer opportunity!
Name of Volunteer Applicant______________________________________________________________
In what capacity have you know this person? _________________________________________________
How long have you known him/her? ________________________________________________________
Is he/she someone you feel is dependable?
Yes___________ No___________
Would he/she be able to follow instructions and adhere to guidelines on issues such as confidentiality and emergency procedures?
Yes___________ No___________
Do you have any reservations about this person’s ability to be a Presence Covenant Volunteer?
Yes___________ No___________
If yes, please explain_____________________________________________________________________
______________________________________________________________________________________
Does this person exhibit good judgment?
Yes___________ No___________
What are some strengths of the applicant? ____________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name: (Please print) __________________________
Signature: __________________________________
Title: ______________________________________
Organization: _______________________________
Date: _______________________
______________________________________________________________________________________
I authorize the above named person to release the information requested to Presence Covenant Medical Center
__________________________________________
Applicant’s Signature
____________________________________
Applicant’s Name (Please print)
Page 9
Date________________________
Dear, _______________________
____________________________ has applied for a volunteer position at Presence Covenant Medical Center. To meet
accreditation requirements, we are requesting your input or feedback regarding your knowledge of the applicant’s strengths and
skills. We have requested information in short-answer format for your convenience, but you are welcome to provide additional
comments. Acceptance of being a volunteer at Presence Covenant Medical Center is contingent upon completion and return of
this form. Please fax or mail to: Mindy Slack, Volunteer Services, Presence Covenant Medical Center, 1400 W. Park Street,
Urbana, Illinois 61801 Fax: 217-337-4709. You may also scan completed form and e-mail to:
pcmcvolunteer@presencehealth.org. Thank you for your assistance in providing for this volunteer opportunity!
Name of Volunteer Applicant______________________________________________________________
In what capacity have you know this person? _________________________________________________
How long have you known him/her? ________________________________________________________
Is he/she someone you feel is dependable?
Yes___________ No___________
Would he/she be able to follow instructions and adhere to guidelines on issues such as confidentiality and emergency procedures?
Yes___________ No___________
Do you have any reservations about this person’s ability to be a Presence Covenant Volunteer?
Yes___________ No___________
If yes, please explain_____________________________________________________________________
______________________________________________________________________________________
Does this person exhibit good judgment?
Yes___________ No___________
What are some strengths of the applicant? ____________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name: (Please print) __________________________
Signature: __________________________________
Title: ______________________________________
Organization: _______________________________
Date: _______________________
______________________________________________________________________________________
I authorize the above named person to release the information requested to Presence Covenant Medical Center
__________________________________________
Applicant’s Signature
____________________________________
Applicant’s Name (Please print)
Page 10
Date________________________
Dear, _______________________
____________________________ has applied for a volunteer position at Presence Covenant Medical Center. To meet
accreditation requirements, we are requesting your input or feedback regarding your knowledge of the applicant’s strengths and
skills. We have requested information in short-answer format for your convenience, but you are welcome to provide additional
comments. Acceptance of being a volunteer at Presence Covenant Medical Center is contingent upon completion and return of
this form. Please fax or mail to: Mindy Slack, Volunteer Services, Presence Covenant Medical Center, 1400 W. Park Street,
Urbana, Illinois 61801 Fax: 217-337-4709. You may also scan completed form and e-mail to:
pcmcvolunteer@presencehealth.org. Thank you for your assistance in providing for this volunteer opportunity!
Name of Volunteer Applicant______________________________________________________________
In what capacity have you know this person? _________________________________________________
How long have you known him/her? ________________________________________________________
Is he/she someone you feel is dependable?
Yes___________ No___________
Would he/she be able to follow instructions and adhere to guidelines on issues such as confidentiality and emergency procedures?
Yes___________ No___________
Do you have any reservations about this person’s ability to be a Presence Covenant Volunteer?
Yes___________ No___________
If yes, please explain_____________________________________________________________________
______________________________________________________________________________________
Does this person exhibit good judgment?
Yes___________ No___________
What are some strengths of the applicant? ____________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name: (Please print) __________________________
Signature: __________________________________
Title: ______________________________________
Organization: _______________________________
Date: _______________________
______________________________________________________________________________________
I authorize the above named person to release the information requested to Presence Covenant Medical Center
__________________________________________
Applicant’s Signature
____________________________________
Applicant’s Name (Please print)
Page 11
BEFORE YOU SUBMIT YOUR PRESENCE COVENANT APPLICATION FORM:
 Have you signed your application form AND background check form? You will
need to provide your social security # at your interview to complete your
application.
 Are you 15 years of age by June 1st, 2015? If you are under 18 years of age,
Have you had a parents sign the second page of your application where it requests
signature of parent or guardian?
 Enclosed are (3) reference forms. Please have these forms completed
and returned by your references. (Please no relatives or college friends)
 Have you attached your MMR record, chicken pox and updated 2-Step TB
results?
 Have you completed the HEALTH SURVEY (reverse side of
application form)?
 Have you marked your personal calendar for the MANDATORY
ORIENTATION testing session on Wed., Aug. 26th between 4 – 6pm?
Please make sure your schedule allows you to commit before submitting your
application.
 Please include a recent photograph (no larger than 2” X 3” wallet size).
 Please call Volunteer Services to schedule an interview (337-2378)
Remember to submit ALL health documents and your completed
background-check form with your application (it is mandatory
to ensure a scheduled placement).
As a volunteer candidate for Presence Covenant Medical Center, I have read, I understand
and I agree to adhere to the orientation and health requirements for a volunteer position. I
will attend the mandatory orientation testing session and meet all necessary health
requirements for a volunteer position. I meet the minimum age requirements of 15 years of
age. Please sign this form and include it in your application submission. Thank you.
__________________________________
Volunteer Candidate Signature
_____________________
Date
Thank you for your application!
Page 12