KAISER PERMANENTE

CJU

ONTARIO
Kaiser Permanente Medical Center
Complete & Return this form
APPLICATION
Date:

Adult

VOLUNTEER
College Student

High

School Student
NameFirst
_________________________________________________________________________________
Middle
Last

Home Phone

_____________________________________

Street Address ________________________________________________________________________

Cellular

Phone ___________________________________
City, State, Zip ______________________________________________________________E-mail Address
______________________________________________
Are you willing and able to commit 100 hours or 1 year of service to Kaiser Permanente?
Are you willing and able to commit to a regularly scheduled 4 hour shift each week?

Yes -
Yes -

No -
No -

In order to evaluate your application and determine whether we will be able to offer you a place on our team, we
would like to get to know you better. As you answer the questions below, please feel free to attach additional
pages if needed. We also encourage you to send a resume, letter of reference or other documents that might
help support your application.
Please share with us why you would like to volunteer at Kaiser Fontana or Ontario Medical Center:

Please describe for us a time when you have interacted with someone who was ill, recovering from surgery or recovering
from mental illness. What were your challenges and successes?

Do you have previous volunteer experience? If yes, please list locations, positions held and dates for your previous
experience. If no, please share life/work experiences that will help you succeed as a volunteer in a hospital.

What experience do you wish to gain while participating in the Kaiser Permanente Volunteer Program:

What tasks or departments are of interest to you?

Do you have any special skills, talents or interests you would be willing to share with us?

__________________________________________________________________________________________
_______________________________

FOR TEEN VOLUNTEERS: TWO LETTERS OF RECOMMENDATION ARE REQUIRED

TO BE RETURNED WITH THE APPLICATION. LETTERS CAN BE FROM TEACHERS,
COACHES, OR PASTORS.
PLEASE HAND-DELIVER COMPLETED FORM TO:
Kaiser Permanente Ontario Medical
Center
2295 S. Vineyard Avenue

ONTARIO MEDICAL CENTER

VOLUNTEER SERVICES APPLICATION
(PLEASE PRINT IN BLUE OR BLACK INK)
TO THE APPLICANT: KAISER FOUNDATION HEALTH PLAN, INC., KAISER FOUNDATION HOSPITALS (TOGETHER KFHP/H), KFHP/HS SUBSIDIARIES, SOUTHERN CALIFORNIA
PERMANENTE MEDICAL GROUP, AND THE PERMANENTE MEDICAL GROUP, INC. (KAISER PERMANENTE) ARE EQUAL OPPORTUNITY VOLUNTEER ORGANIZATIONS.
KAISER PERMANENTE MAKES VOLUNTEER PLACEMENT DECISIONS BASED ON QUALIFICATIONS ONLY WITHOUT REGARD TO RACE, RELIGION, COLOR, NATIONAL
ORIGIN, ANCESTRY, SEX, AGE, MARITAL STATUS, DISABILITY, MEDICAL CONDITION, SEXUAL ORIENTATION, VETERAN STATUS, OR OTHER NON-JOB RELATED FACTORS
PROHIBITED BY APPLICABLE FEDERAL, STATE, OR LOCAL LAWS. KAISER PERMANENTE PROVIDES APPLICANTS WHO HAVE DISABILITIES WITH REASONABLE
ACCOMMODATION TO ASSIST IN THE INTERVIEW/VOLUNTEERING PROCESS. APPLICANTS REQUIRING ACCOMMODATION SHOULD CONTACT THE VOLUNTEER
DIRECTORS OFFICE. KAISER PERMANENTE IS A SMOKE-FREE WORKPLACE. THIS DOCUMENT MUST BE COMPLETED IN ITS ENTIRETY BEFORE VOLUNTEER PLACEMENT
CAN BE AUTHORIZED.

PERSONAL DATA
NAME (LAST)
ADDRESS (NUMBER)

(FIRST)

(MIDDLE)

(STREET)

(APARTMENT #)

TODAYS DATE
HOME / CELL TELEPHONE

(
CITY

STATE

ZIP CODE

EMAIL
EMERGENCY CONTACT PERSONS (NAMES AND TELEPHONE NUMBERS)

1)
2)
HOW DID YOU HEAR ABOUT THE FMC KAISER PERMANENTE VOLUNTEER SERVICES PROGRAM?
COUNSELOR/TEACHER
FRIEND
SCHOOL CAREER FAIR
PRESENTATION
BROCHURE
KAISER PERMANENTE EMPLOYEE
SYEP WEBSITE
OTHER: __________________________
HAVE YOU EVER BEEN EMPLOYED BY KAISER PERMANENTE OR
ANY OTHER KAISER ORGANIZATION?
YES
NO

IF YES, NAME OF FACILITY OR ORGANIZATION

WHERE

POSITION HELD

WHEN
NAME USED

DO YOU HAVE RELATIVES WORKING FOR KAISER PERMANENTE? IF YES, INDICATE NAME, RELATIONSHIP, DEPARTMENT, LOCATION

YES

NO

WHY DO YOU WANT TO VOLUNTEER?

PERSONAL FULFILLMENT
SCHOOL REQUIREMENT
OTHER: __________________________

COURT ORDERED COMMUNITY SERVICES

REFERENCES
(NON-RELATIVES)
NAME

TELEPHONE NUMBER

HOW DOES THIS PERSON KNOW YOU

OCCUPATION

NAME

TELEPHONE NUMBER

HOW DOES THIS PERSON KNOW YOU

OCCUPATION

EDUCATION INFORMATION
CURRENT SCHOOL NAME

COLLEGE ATTENDED/ATTENDING:

COUNSELORS NAME

GRADE YOU WILL COMPLETE THIS YEAR

EMPLOYMENT & VOLUNTEER EXPERIENCE

LIST CURRENT AND PREVIOUS WORK EXPERIENCE (INCLUDE VOLUNTEER WORK)
COMPANY NAME / ADDRESS / PHONE
DATES EMPLOYED
JOB TITLE AND DUTIES PERFORMED
FROM:

TO:

TITLE:
DUTIES:

FROM:

TO:

TITLE:
DUTIES:

FROM:

TO:

TITLE:
DUTIES:

FROM:

TO:

TITLE:
DUTIES:

LANGUAGE PROFICIENCY (OTHER THAN ENGLISH)

LANGUAGE

READS

AMERICAN SIGN LANGUAGE (SIGN)

WRITES

YES

SPEAKS

NO

SKILLS
CHECK SKILLS THAT YOU POSSESS
TYPING

WORDS PER MINUTE

COMPUTER SKILLS

OTHER

SKILLS

SKILLS, INTERESTS, AND HOBBIES:

NUMBER OF SEMESTERS

TYPE OF SOFTWARE USED (CHECK ALL THAT APPLY)

INDICATE SKILL LEVEL: BEGINNING (B), INTERMEDIATE (I), OR ADVANCED (A)
EXCEL
MICROSOFT WORD
POWERPOINT
ACCESS
ADOBE PHOTOSHOP
DESKTOP PUBLISHING
OTHER

_________________________

ONTARIO MEDICAL CENTER

VOLUNTEER SERVICES APPLICATION CONTINUED

(PLEASE PRINT IN BLUE OR BLACK INK)

REFERENCES
(NON-RELATIVES)
PRINT FULL NAME

LAST

FIRST

MIDDLE

ADDRESS

NUMBER

STREET

CITY

STATE

ZIP CODE

COUNTY

FROM

PRINT FULL NAME

LAST

FIRST

MIDDLE

ADDRESS

NUMBER

STREET

CITY

STATE

ZIP CODE

COUNTY

FROM

PRINT FULL NAME

LAST

TO

FIRST

TO

MIDDLE

ADDRESS

NUMBER

STREET

CITY

STATE

ZIP CODE

COUNTY

FROM

TO

APPLICANT STATEMENT
THIS APPLICATION IS SUBMITTED WITH THE UNDERSTANDING THAT ALL VOLUNTEER PLACEMENTS ARE CONDITIONAL AND WILL NOT BE
CONFIRMED UNTIL SATISFACTORY COMPLETION OF A PRE-VOLUNTEER HEALTH-SCREENING AND BACKGROUND CHECK . I HEREBY CONSENT
TO SUCH REQUIRED SCREENING AND TO THE INCLUSION OF A STATEMENT WHETHER I HAVE PASSED OR FAILED THE SCREENING IN MY
PERSONNEL FILE.
I HEREBY AUTHORIZE KAISER PERMANENTE TO SOLICIT ALL INFORMATION RELEVANT TO THIS APPLICATION. THIS AUTHORIZATION
INCLUDES BUT IS NOT LIMITED TO A CRIMINAL RECORDS CHECK, MY ACADEMIC BACKGROUND, EMPLOYMENT HISTORY AND FEDERAL OR
STATE SANCTIONS/EXCLUSIONS. I AUTHORIZE AND REQUEST ALL PERSONS, SCHOOLS, COMPANIES, CORPORATIONS, GOVERNMENTAL,
LAW ENFORCEMENT, AND OTHER AGENCIES TO RELEASE SUCH REQUESTED INFORMATION TO KAISER PERMANENTE.
I CERTIFY THAT THE ANSWERS I HAVE PROVIDED ABOVE ARE TRUE, CORRECT, AND COMPLETE. I UNDERSTAND ANY FALSIFICATION,
MISREPRESENTATION, OR OMISSION OF FACTS IS SUFFICIENT REASON FOR DISQUALIFICATION FROM FURTHER CONSIDERATION.
I ALSO UNDERSTAND THAT IF I AM A VOLUNTEER AT KAISER PERMANENTE, MY VOLUNTEER STATUS CAN BE TERMINATED AT ANYTIME
WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I UNDERSTAND THAT A COPY OF THIS DOCUMENT IS AVAILABLE TO ME IF I SO
DESIRE.
IF UNDER THE AGE OF 18, PLEASE PROVIDE YOUR BIRTHDATE: _______________________________________.
THE MINIMUM AGE TO VOLUNTEER AT KAISER PERMANENTE HOSPITAL IS FOURTEEN (14) YEAR OLD. BY SIGNING
18.
SIGNATURE: __________________________________________________________________
APPLICANTS SIGNATURE

DATE

PARENTAL CONSENT (IF UNDER 18)

DATE

HERE, I ATTEST THAT I AM UNDER THE AGE OF