Uf Health Shands Volunteer Services Department Adult Application Form Page 2
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2UF Health Shands Volunteer Services Department
Adult Volunteer Application
Contact Information
Name
Male Female
Local Address
City/ ST/ ZIP
Phone
Date of Birth
E-Mail Address
Person to Notify in Case of Emergency
Name
Phone
Relation to person
Questions (Circle Answers)
1. Have you picked up the TB Surveillance Form and been cleared by Occupational Health?
NO
YES
Remember: you need to have your immunization records in hand at Occupational Health.
2. Do you need special accommodations?
NO
YES
3. Have you been convicted, pleaded “nolo contendere”, or had adjudication withheld for any crime or offense
(excluding minor traffic violations)?
NO
YES
Please explain any YES answers to questions 2 and 3:
Service Areas:
Refer to the website for further information about each service area ( ).
Placement interviews available for each area listed below. Volunteer schedules are based on availability.
General Service Areas
Specialized Programs
___ Alz’s Place or Eldercare
___ Pediatrics
___ Arts in Medicine
___ Clinics
___ Pharmacy
___ Child Life Program
___ Customer Service
___ Psychiatry/Psychology
___ Patient Advocate Liaison (PAL)
___ Emergency Department
___ Radiology
___ Pet Visitation
___ Gift STOP
___ Rehab Services (OT/PT)
___ No One Dies Alone (NODA)
___ Labs
___ UF College of Dentistry
___ Ronald McDonald Family Room
___ Nursing
___ Orthopedics
___ Streetlights
___ Footprints
Placement Interview Checklist:
Completed application
Online orientation quiz results page (sign and date)
Volunteer Service Record
(provided when you pick up the TB Surveillance Form and signed by Occupational Health)
Immunization record
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Parent category: Business