Hospital of the University of Pennsylvania

Nursing & Allied Health Online Application for the Hospital of the University of Pennsylvania

This online application is for the Allied Health & Nursing Volunteer Program at the Hospital of the University of Pennsylvania. If you are interested in a different program, please choose: Adult, Premed, or Teen.

Note: This application is not secure in that it does not use 128-bit encryption to transfer information from your computer to our system. The information that you provide will be kept confidential and used only for the purpose of Volunteer Services at the Hospital of the University of Pennsylvania.

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Full Name

Title:  

Mr. Miss Ms. Mrs.

First:  

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Middle:  

Last:  

This field is required

Date of Birth:  


Enter (mm/dd/yyyy)

Local Address

Street Address:  

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Apt. / P.O. Box / Suite:  

City / Town:  

This field is required

State:  

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Zip:  

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Permanent Address

Street Address:  

Apt. / P.O. Box / Suite:  

City / Town:  

State:  

Zip:  

Phone / Email

Daytime Phone Number:  

This field is required

Second Phone Number:  

Cell Phone:  

Email Address:  

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Re-type Email Address:  

This field is required

Emergency Contact Information

Contact Name:  

This field is required

Relationship to you:  

This field is required

Phone Number:  

Additional Information

Describe your interest in a volunteer position at HUP: This field is required

 

Are you currently seeking volunteer service to fulfill a community service obligation (school, church, court referred)? This field is required

Yes No

If yes, please describe the service requirements:

Community Service  
Organization Contact:  

Phone Number:  

 

Is there anything that may adversely affect your ability to perform volunteer work, or that would require an accommodation in order for you to safely and competently perform volunteer work as requested? This field is required

Yes No

If yes, please describe, including details and accommodation requirements. The information you provide will be kept confidential.

Education

Please indicate the highest level of education completed.

High School:  

9 10 11 12

High School Name:  

High School Address:  

College:  

1 2 3 4

Graduate School:  

1 2 3 4

College Name:  

Degree or Major:  

 

Do you currently hold any medical licenses (foreign or domestic)? This field is required

Yes No

If yes, explain:

 

Have you ever been licensed to practice medicine, in this country or any other? This field is required

Yes No

If yes, explain:

 

Are you currently, on a career path to medical school or physician assistant school? If yes, when is the projected date you plan to apply (month/year)? This field is required

Yes No

If yes, when (month/year):

 

Are you currently enrolled in nursing school/have you ever completed nursing school? This field is required

Yes No

If yes, explain:

Employment Experience

Please complete the following based on employment held within the last 10 years.

Have you ever worked for HUP or any entity of the University of Pennsylvania Health System? This field is required

No    Yes    Currently employed by UPHS

If yes, work location:  

Dates of employment:  

Reason for leaving:  

 

Current    or past employer

Business Name:  

Business Address:  

Business Phone Number:  

Position Title:  

Supervisor's Name:  

 

Current    or past employer

Business Name:  

Business Address:  

Business Phone Number:  

Position Title:  

Supervisor's Name:  

 

Current    or past employer

Business Name:  

Business Address:  

Business Phone Number:  

Position Title:  

Supervisor's Name:  

 

Current    or past employer

Business Name:  

Business Address:  

Business Phone Number:  

Position Title:  

Supervisor's Name:  

References

Please provide complete information on two references. Current or former job supervisors, teachers, or clergy persons may serve as references. Family members, relatives and friends may not provide recommendations on your behalf.

Reference #1

Name:  

This field is required

Relationship to you:  

This field is required

Name of business or school:  

This field is required

Address:  

This field is required

Telephone number:  

This field is required

Reference #2

Name:  

This field is required

Relationship to you:  

This field is required

Name of business or school:  

This field is required

Address:  

This field is required

Telephone number:  

This field is required

Criminal Background Check

Have you ever been convicted of a felony? This field is required

Yes No

Have you ever been convicted of a misdemeanor? This field is required

Yes No

If you answered Yes to either of these two questions regarding convictions, please describe the conviction(s) in detail, including dates:

Application Certification

Click here to certify the application: This field is required

I certify that the information I have provided on this application is true and complete to the best of my knowledge. I understand that misrepresentation, falsification, or omission of information may disqualify me from further consideration for volunteering, or may result in my termination as a volunteer at the Hospital of the University of Pennsylvania. If accepted as a volunteer, I understand that I must abide by all of the policies, rules and regulations of the Hospital.

I authorize the Hospital of the University of Pennsylvania Volunteer Services Department to investigate all statements contained in this application and to make inquiries of my personal referencesand medical history, as well as other related matters as may be necessary for determining my eligibility as a volunteer. I hereby release employers, schools or individuals from all liability in responding to inquiries relating to my volunteer application.

Submit

If you are satisfied with your application, please press the "Submit" button below. Your application is not complete until you press "Submit."

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