Volunteer Application

Thank you for your interest in volunteer opportunities with Portneuf Medical Center. Please complete this online application, which includes a brief medical and health history and an approval for a criminal background check.

When you click 'submit' at the end of the application form, you give your consent for us to conduct a criminal background check.

Once you have been cleared with employee health and your background check has been completed, we will contact you to set up an appointment.

Thank you for your interest in being a part of our team!

For Questions or to Schedule an Appointment, please contact:

Wendy Andersen, Director of Volunteer Services and Human Resources at wendy.andersen@portmed.org or by calling 208-239-1485.

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Secondary Phone Number

Street Address *

Address Line 2

City *

State *

ZIP Code *

Volunteer Information

Type of Volunteer *

For College Students - Program of Study

We are no longer taking applications for this summer session. Please check back next March.

Why do you want to volunteer at Portneuf? *

References

Previous Volunteer Experience

Dates or Length of Time

Reference First Name

Reference Last Name

Reference Contact Number

Medical

Medical Restrictions *

Yes

Do you have any medical conditions, health concerns or physical restrictions that could limit or restrict your volunteer duties?

If "Yes," please describe

Emergency Contact *

Relationship *

Phone Number *

Secondary Phone Number

Your Physician *

Physician Phone *

Education / Skills

Highest level of education completed *

Are you currently taking classes? *

Yes

Educational Information

Program or Area of Study

Name of most recent school or institution

City

State

Dates of Attendance (year)

Year of Graduation/Completion

Name on Diploma/Certificate/GED

Special Training or Other Education

Other Hobbies, Skills, Special Interests

Background Check

First Name *

Middle Name

Last Name *

Maiden Name

Social Security Number - required for background clearance

Date of Birth *

Month

Day

Year

Any other names used

Driver's License Number *

State Driver's License is Issued *

Criminal Background Information *

Yes

Have you ever been convicted of a crime, including felonies, misdemeanors or deferred adjunctions? Please note: a conviction will not automatically disqualify you from a volunteer consideration.

Offence

County

State

Date Of Offence

Month

Day

Year

Previous Residencies

Please provide all locations where you have resided for the past seven years starting with your current residency. When you fill one set of fields, another set will appear.

City 1 *

State 1 *

Dates 1 *

City 2

State 2

Dates 2

City 3

State 3

Dates 3

City 4

State 4

Dates 4

City 5

State 5

Dates 5

Volunteer Disclosure and Release

Pursuant to the requirements of the Fair Credit Reporting Act, I acknowledge that a credit report, consumer report2 and/or investigative consumer report3 may be made in connection with my application for employment with prospective employer,including contract for services. I understand that these investigative background inquiries may include credit, consumer, criminal, driving, prior employment and other reports. These reports may include information as to my character, work habits performance and experience, along with reasons for termination of past employment from previous employers. Further, I understand that a prospective employer and PreCheck, Inc. may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my educational/school records, driving, credit, criminal, civil and other experiences, as well as claims involving me in the files of insurance companies.

I authorize, without reservation, any party or agency contacted by PreCheck, Inc. to furnish the information mentioned above. A photocopy of this authorization shall have the same effect as the original.

I understand the information obtained will be used as one basis for employment/contract for services or denial of employment/contract for services. I hereby discharge, release and indemnify the prospective employer, PreCheck, Inc., their agents, servants and employees, and all parties that rely on this release and/or the information obtained with this release from any and all liability and claims arising by reason of the use of this release and dissemination of information that is false and untrue if obtained from a third party without verification.

It is expressly understood that the information obtained through the use of this release will not be verified by PreCheck, Inc. The authorization granted herein shall be effective throughout the term of my employment.

Applicant's Signature *

Today's Date *

Month

Day

Year

Parent/Guardian’s Signature (if volunteer is under 18)

Upon your written request within a reasonable period of time, the investigative agency compiling a report will make a complete and accurate disclosure of the nature and scope of the investigation. In addition, if you are denied employment, either wholly or partly because of information contained in a consumer report, a disclosure will be made to you of the name and address of the investigative agency making such a report.

₁The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. This information is for consumer report purposes only. A “Consumer Report” may consist of employment records, educational verification, licensure verification, driving record, previous address and public records relative to criminal charges. 3 An “Investigative Consumer Report” means a consumer report or portion thereof in which information on a consumer’s character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with persons having knowledge.

Thank you for your interest in Portneuf Medical Center. Please submit your application.

Have a great day.

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Volunteer Application Form

Volunteer Application