Hospital of the University of Pennsylvania

Full Name

Title:  

Mr.   Miss   Ms.   Mrs. 

First:  

Middle:  

Last:  

Date of Birth:  

Enter (mm/dd/yyyy)

Local Address

Street Address:  

Apt. / P.O. Box / Suite:  

City / Town:  

State:  

Zip:  

Permanent Address

Street Address:  

Apt. / P.O. Box / Suite:  

City / Town:  

State:  

Zip:  

Phone / Email

Daytime Phone Number:  

Second Phone Number:  

Cell Phone:  

Email Address:  

Re-type Email Address:  

Emergency Contact Information

Contact Name:  

Relationship to you:  

Phone Number:  

Additional Information

Describe your interest in a volunteer position at HUP: 

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

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?

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)?

Yes No

If yes, explain:

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

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)?

Yes No

If yes, when (month/year):

Are you currently enrolled in nursing school/have you ever completed nursing school?

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?

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:  

Relationship to you:  

Name of business or school:  

Address:  

Telephone number:  

Reference #2

Name:  

Relationship to you:  

Name of business or school:  

Address:  

Telephone number:  

Criminal Background Check

Have you ever been convicted of a felony? 

Yes No

Have you ever been convicted of a misdemeanor? 

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:

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 liability in responding to inquiries relating to my volunteer application.

Submit

If you are satisfied with your application, please press the "Submit" button below.
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