Affinity Health System

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Volunteer with us. You'll help provide better care for patients throughout Northeast Wisconsin.

Please complete the online application form below. After we receive your application and check your references, you will be contacted by Volunteer Services staff.

If the applicant is younger than 18 or requires legal guardianship, also download the Patient/Guardian Permission Form linked to the right for the facility where you wish to volunteer. Please print, sign and bring this permission form to the Volunteer Office at the time of your initial appointment.

Thank you for your interest in volunteering at our Affinity Health System facilities!

At which facility do you wish to volunteer?*

Mercy Medical Center, 500 S. Oakwood Rd., Oshkosh
St. Elizabeth Hospital, 1506 S. Oneida St., Appleton

Please indicate your status:*

Adult
College Student
Teen

Date of birth:* Month, Day, (Year is optional)

Applicant Information

Name:* Last, First, MI

Home Phone:*

Work Phone:

Cell Phone:

May we share your telephone number(s) with other Affinity Health System volunteers and/or departments for volunteer scheduling purposes?*

Yes

Home or Mailing Address* Number and Street. City, State, Zip

E-mail Address:

Alternate Address/Phone: Number and Street, City, State, Zip, Phone

Emergency Contact Information

Name of Emergency Contact Person:*

Relationship:*

Daytime Phone:*

Evening Phone:*

Employment/School Information

Employer (present/last):

Business Phone: (if we may call you at work)

Occupation:

Job Duties:

Dates of Employment:

School Attending:

Grade level:

Graduation Date:

Or

Education (highest level completed):

Training/Study:

Are you here to fulfill a school requirement?*

Yes

Previous or Current Volunteer Experience

Place:

Duties:

Place:

Duties:

Are you currently working or have you ever worked at Affinity Health System?*

Yes

If yes, when?

Facility:

Department:

Have you ever volunteered for Affinity Health System in the past?*

Yes

How did you hear about our volunteer program?*

Why do you feel you should be selected to become a volunteer?*

Background Information

Do you have any physical or mental disabilities that may limit your ability to perform the essential functions of any volunteer position you may be assigned?*

Yes

If yes, please describe what can be done to accommodate these limitations.

Are you applying to fulfill court-ordered community service?*

Yes

Have you ever been convicted of a felony, misdemeanor, or other criminal offense (including a civil forfeiture), or are any criminal charges pending against you?* Conviction or pending charges may not automatically disqualify an applicant from consideration for a position. The conviction for the crime will be considered as it relates to the volunteer assignment.

Yes

If yes, describe in full, including date(s).

Has it ever been determined by any county that you have abused or neglected a child?*

Yes

If yes, describe in full, including date(s).

Are you currently using illegal drugs (i.e. within the past 30 days?)*

Yes

If yes, furnish details.

References: List two adults able to attest to your character and reliability, other than relatives and personal friends (i.e., employer, teacher, counselor).

1. Name:*

Street Address:*

City/State/Zip:*

Phone:*

E-mail Address:

Relationship to Applicant:*

2. Name:*

Street Address:*

City/State/Zip:*

Phone:*

E-mail Address:

Relationship to Applicant:*

Areas of Interest

Please check your areas of interest and skills as a volunteer. (Not all areas are available at all Affinity facilities.)*

Helping Patients
Errands/Delivery/Wheelchair Transport
Spiritual Service
Hair Care
Pet Therapy
Performing Arts/Singing/Instrument
Health Screening
RN
Children
Tour Guide
Gift Shop
Fundraising
Filing/Photocopying
Computer
Mailings/Short-term projects
Receptionist
Bookkeeping
Bulletin Boards/Displays
Calligraphy/Handwriting
Newsletter/Publicity
Audio-visual/Photography
Crocheting/Knitting
Handicrafts
Quilting/Sewing
Plants/Yard Work
Other
Undecided

If other, please specify:

Please check the days and times you are most often available to volunteer.

Sunday

Morning

Afternoon

Evening

Monday

Morning

Afternoon

Evening

Tuesday

Morning

Afternoon

Evening

Wednesday

Morning

Afternoon

Evening

Thursday

Morning

Afternoon

Evening

Friday

Morning

Afternoon

Evening

Saturday

Morning

Afternoon

Evening

I'm available in:

Spring
Summer
Fall
Winter

Volunteer Agreement: Please check "I accept" next to each statement to indicate you have read and understood the following.

I shall not disclose to seek or obtain any information concerning patients/residents, doctors or personnel. I understand that the giving of information concerning a patient/resident to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.*

I accept

I decline

I voluntarily offer my services with a clear understanding that there is no monetary compensation or the expectation of future employment.*

I accept

I decline

I shall be punctual, conscientious, courteous, considerate, and conduct my work in a professional manner.*

I accept

I decline

I shall attempt to resolve any problems/concerns related to my volunteer activities with my supervisor and, if needed, will contact the Volunteer Services department for possible solutions.*

I accept

I decline

I shall make every effort to fulfill my commitment to Affinity Health System by completing all assignments that I accept. After a three-month orientation period, I agree to be reviewed by the department designee to evaluate if my placement is in the best interest of myself and the department. Once placed, a minimum time commitment shall be determined, preferably six months to one year. Thereafter, periodic reviews may be done by the department designee to evaluate my volunteer performance.*

I accept

I decline

I agree to attend periodic inservices. Federal and health care accreditation agencies require inservices for all volunteers to maintain consistent performance levels. These inservices provide training, updates and interaction with department staff.*

I accept

I decline

I shall, at all times, uphold the mission, vision and values of Affinity Health System and the Volunteer Services department.*

I accept

I decline

I understand that the Volunteer Services department reserves the right to terminate my volunteer status as a result of (a) failure to comply with policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the department manager, would make my continued services as a volunteer contrary to the best interests of Affinity Health System.*

I accept

I decline

Beyond my specified duties, I pledge to serve as an ambassador on behalf of Affinity Health System. I have reviewed, understand and agree to the above conditions.*

I accept

I decline

Agreement to Investigation and Release: Please check "I accept" next to each statement to indicate you have read and understood the following.

I authorize any screening required by Affinity Health System and understand my volunteer assignment is contingent upon successful completion of the screening. I understand that a criminal background check and information received from this application (and/or resume, if submitted) will be used for determining my eligibility for volunteering.*

I accept

I decline

I release from any and all liability all representatives of Affinity Health System for their acts performed in good faith and without malice in connection with evaluating my volunteer application. I further authorize any party having information bearing upon my qualifications to release such information to Affinity Health System and also release any party from liability in sharing this information with Affinity Health System. I also authorize Affinity Health System to release similar information to prospective employers.*

I accept

I decline

I certify that my statements in this application are true and complete, and I authorize investigation of the statements I have made. I understand that falsification of this application constitutes grounds for rejection or termination from Affinity Health System.*

I accept

I decline

My typed name below shall have the same force and effect as my written signature.* Please type your first and last name with middle initial.

Application Date:

(mm/dd/yyyy)

Non-discrimination

Please check the box to indicate you have read and understand the following statement:*

Opportunities for volunteers within Affinity Health System are provided without regard to age, race, religion, creed, color, disability, marital status, sex, national origin, ancestry, sexual orientation, military reserve status and any other unlawful basis.

Send the form

Apply Now!

Volunteer with us. You'll help provide better care for patients throughout Northeast Wisconsin.

Applicant Information

Emergency Contact Information

Employment/School Information

Or

Previous or Current Volunteer Experience

Background Information

References: List two adults able to attest to your character and reliability, other than relatives and personal friends (i.e., employer, teacher, counselor).

Areas of Interest

Please check the days and times you are most often available to volunteer.

Volunteer Agreement: Please check "I accept" next to each statement to indicate you have read and understood the following.

Agreement to Investigation and Release: Please check "I accept" next to each statement to indicate you have read and understood the following.

Non-discrimination

Helpful Resources

Permission Forms