Hospital of the University of Pennsylvania

Premed Online Application for the Hospital of the University of Pennsylvania

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

This field is required

Middle:  

Last:  

This field is required

Date of Birth:  


Enter (mm/dd/yyyy)

Local Address

Street Address:  

This field is required

Apt. / P.O. Box / Suite:  

City / Town:  

This field is required

State:  

This field is required

Zip:  

This field is required

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

In the event of an emergency, who should we contact?

Contact Name:  

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Relationship to you:  

This field is required

Phone Number:  

Additional Information

Are you currently volunteering at HUP?

Yes No

Have you previously completed one session (48+ hours of service over 13 weeks) of the college volunteer program at HUP?

Yes No

If yes, indicate the most recent month and year
of service (mm/yyyy).

 

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

Availability

Please indicate the days and times that you are available to volunteer.

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning:
Afternoon:
Evening:

Assignment Preference

We have many opportunities at HUP. Please review the College Volunteer Assignments link on the Program Overview page for unit or department descriptions. Due to demand and scheduling conflicts, your preferred assignment(s) may not be available. Volunteer Services will schedule assignments in the order in which completed applications are received, according to stated availability and preferred location. Please select the top 3 opportunities that may interest you.

First Preference:  

Second Preference:  

Third Preference:  

Education

Please indicate the highest level of education completed. Select only one:

Some high school
High School/GED
Some college
Bachelor's Degree
Master's Degree
Advanced Graduate work or Ph.D.

Employment Experience

Please complete the following based on employment.

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

An email will be sent to your address from Skill Survey. Please follow the instructions in the email to begin the referral process. You will need to provide two email addresses to receive a brief email survey about you, the applicant. Responses must be received no later than five (5) business days after the close of the application period.

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

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 references and 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 liabilityin responding to inquiries relating to my volunteer application.

Click here to certify the application: This field is required

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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