Volunteer Sign Up

JEFFERSON REGIONAL MEDICAL CENTER IS AN EQUAL OPPORTUNITY EMPLOYER. NO QUESTIONS ON THIS APPLICATION ARE ASKED FOR THE PURPOSE OF LIMITING OR EXCLUDING ANY APPLICANT’S CONSIDERATION FOR VOLUNTEER SERVICE BECAUSE OF RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, SEXUAL ORIENTATION, DISABILITY, OR VETERAN STATUS.

Download and complete the paper application or complete the email form below.

Personal

First Name *

Middle Name/Initial

Last Name *

Telephone *

Mobile Phone

Address *

City or Town *

State *

ZiP *

Email Address

Birth Date

Month

Day

Year

Age *

Volunteer Type *

Adult

Middle/High School Student

College Student

Intern

Experience

Education

Work Experience / Career Plans

Volunteer Experience

Special Training (hobbies or interests)

Medical Information

Emergency Contact *

PERSON TO CONTACT IN CASE OF EMERGENCY

Physical Limitations

AT THE PRESENT TIME, IS THERE ANY PHYSICAL CONDITION WHICH COULD LIMIT PARTICIPATION IN THE VOLUNTEER PROGRAM? IF YES, EXPLAIN.

Your Physician's Name

Physician's Phone

Background

Why are you interested in volunteering? *

Have you ever volunteered at Jefferson Regional Medical Center?

IF YES, please provide dates. Note that Jefferson Regional Medical Center was formerly St. Joseph's Homestead Hospital and South Hills Health System (SHHS).

Have you ever been employed by Jefferson Regional Medical Center?

IF YES, PLEASE PROVIDE POSITION. INCLUDE POSITIONS WITH ST. JOSEPH'S HOMESTEAD HOSPITAL OR SOUTH HILLS HEALTH SYSTEM (SHHS).

How did you find out about our program?

Conviction, Guilty Plea or No Contest Plea *

No

Yes

HAVE YOU EVER BEEN CONVICTED OF, PLEADED GUILTY TO, OR ENTERED A PLEA OF NOLO CONTENDERE (NO CONTEST) TO ANY VIOLATION OTHER THAN A SUMMARY OFFENSE.

Accelerated Rehabilitative Disposition (ARD) *

No

Yes

HAVE YOU EVER ACCEPTED ACCELERATED REHABILITATIVE DISPOSITION (ARD), PROBATION WITHOUT VERDICT (PWV) OR A SIMILAR COURT MONITORED PROGRAM OTHER THAN A SUMMARY OFFENSE?

If Yes, please explain:

Reference #1

Name

Relationship

Phone

Address

City or Town

State

Zip

Reference #2

Name

Relationship

Phone

Address

City or Town

State

Zip

Applicant's Signature

I CERTIFY THAT ALL STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT, MISREPRESENTATION OR OMISSION MAY CAUSE MY DISMISSAL FROM VOLUNTEER SERVICE.

Jefferson Regional Medical Center
565 Coal Valley Road
Jefferson Hills, PA 15205
412-469-5000

Physician Referral:
412-469-7000

Community Programs:
412-469-7100

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