Apply to Volunteer at Henry Ford West Bloomfield Hospital

Volunteer Application Adult College Research (Certain Sites) Summer High School Shadow/Observation

We are unable to accept your application if you do not have an accepting provider or department to approve you for shadowing.

Applicant Information

First Name Middle Initial Last Name Gender Name (Preferred) Date of Birth Home Address City State ZIP Code Mobile Phone Home Phone Email Address Are you 18 years of age or older? Yes No Are you a citizen of the US? Yes No If not a US citizen, do you possess a valid U.S. immigration status that authorizes you to be lawfully present in the U.S. and to volunteer at a health care facility for duration of your proposed volunteer service? Yes No

Prior or Existing Work or Volunteer Experience: Please include occupation/title/volunteer experience, organization, and years experience.

Prior work or volunteer experience Hobbies: Special Skills: Languages you speak fluently: How did you learn about our volunteer program, and what appeals to you about volunteering in a healthcare setting? Are you a Henry Ford Health employee? Yes No If yes, which Henry Ford Health site? Does your immediate family member work or volunteer for Henry Ford Health? Yes No If you are a student, please list school attending, current grade & anticipated date of graduation: Are you volunteering to meet an academic or other program requirement? Yes No

Availability

Typical volunteer commitment is a minimum 4 hours per week for a period of 15 weeks or more.

How many hours per week do you want to volunteer? Date you can start volunteering End date, if applicable

List times that you are available to volunteer:

Emergency Contact

Contact Name Relationship Telephone Number Email

Reference

Name Relationship Telephone Best Time to Reach

Application Agreement

I certify that all information I have and will provide throughout the selection process, including on this application and in interviews with Henry Ford Health (HFH), is true, correct, and complete to the best of my knowledge. I understand that information I provide may be verified and references may be contacted by HFH. I understand that misrepresentations or omissions may be cause for my immediate termination as a volunteer.

Agree Date

Henry Ford Health Volunteer Agreement Statement

I understand that if I am selected as a volunteer at Henry Ford Health I am agreeing to the Henry Ford Health Volunteer Agreement Statement (Full statement is available at henryford.com/volunteer-agreement).

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