Application For Voluntary Service Page 2
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2NOTE TO STUDENTS AND PARENTS: The VA medical center is a federal building, and, as such, must be open to the
public. Our employees, patients, and volunteers come from diverse backgrounds. Eligible Veterans are entitled to
services offered by VA, even if they have had problematic incidents in their past - unless the law specifically
disqualifies them. Our job is to provide care to Veterans and to protect our employees, patients, and volunteers as
that care is provided.
STUDENT VOLUNTEER: If accepted, I agree to adhere to the policies and procedures of this VA healthcare facility and
to respect the confidentiality of information pertaining to the patients and their treatment. If a patient, staff
member, volunteer, and/or visitor is abusive, makes inappropriate gestures, advances, or conversation, that is in a
manner which makes me feel uncomfortable, I will immediately inform my supervisor or a VAVS staff member.
Signature____________________________________________
Date _________________
PARENT/GUARDIAN: The above named student has my consent as parent/guardian to serve as a Student Volunteer
in this VA healthcare system. I have read the above agreement as signed by my student and understand their
obligation to the program if they are accepted into the VAVS Student Volunteer Program. I also grant permission for
my child to receive emergency medical treatment if injured while volunteering.
Signature____________________________________________
Date __________________
NOTE: Completion of this application does not guarantee acceptance into this program.
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