Please complete this application form if you are age 18+, and you are interested in becoming a Stamford Health volunteer.

 

Most of our programs require two 3-hour shifts per week for six months. Select programs require one shift per week for 3- to 4- hours. Please consider carefully whether you have the time in your schedule to make this minimum six-month commitment before applying.

Once you complete the form, click the Submit button at the bottom.

Name and address

Demographic Information

If you are under the age of 18, please fill out this application instead: Junior Volunteer Application

Availability

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Assignment Preference

Please share with us your preference for your assignment. Note: We cannot guarantee your placement in your preferred assignment due to availability and other circumstances.

Essay

Qualities and Characteristics

Skills and Hobbies

Employment

Referral

History with us

Have you ever been convicted of a crime?

If you answered yes, please describe the nature of the offense, the date of the conviction(s) and the nature of any rehabilitation. If you are selected to move through the onboarding process, Stamford Health will perform a background check through a third-party vendor.

Note: you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes 46-b-146, 54-76o or 54-142a. Criminal records subject to erasure pursuant to Connecticut General Statues 46b-146, 54- 76o or 54-142a are records related to (a) determinations of "delinquency" or that, as a child, you were a member of a family with service needs, (b)a ruling you are a "youthful offender", (c) a criminal charge that has been dismissed or knolled: (d) finding you are not guilty for a criminal charge, or € a conviction for which you have received an "absolute pardon". Any person whose criminal records have been erased pursuant to Connecticut General Statues Sections 46b-146, 54- 76o or 54-142a shall be deemed to never have been arrested within the meaning of the general statutes with respect to the proceedings so erased and many so swear under oath.

With the exception of any arrest, criminal charge, or conviction which may have been erased pursuant to the statues listed above, any misrepresentation or omissions with respect to an applicant's or an employee's criminal history will be grounds for termination of an employee or volunteer, or a decision not to assign or accept an applicant.  

Disclaimer

Nothing contained in this volunteer application shall be deemed to create an employment contract between Stamford Hospital and myself for either employment or for the providing of any benefit. The granting of an interview shall likewise not create such a contract.

No promises regarding my volunteering or inducements to volunteer have been made or offered to me and I understand and agree that no such promises are binding upon Stamford Hospital unless made in writing and signed by the chief executive officer of Stamford Hospital.

If I am selected as a volunteer, I understand and agree that I have the right to terminate the volunteer relationship at any time and for any reason and the Stamford Hospital have a similar right.

After receiving a conditional offer to participate in a volunteer program, I may be asked to submit to a physical examination that includes a drug test. Any offer to participate in a volunteer program is contingent upon my satisfactory completion of the physical examination, satisfactory references verification, and receipt of a negative drug test result. Such drug test shall be conducted in conformity with the Connecticut drug testing statute (Conn. Gen. Stat. 31-51t to 51aa).

I hereby give Stamford Hospital to which I am applying for a volunteer position, and their agents, permission to undertake verification of the information I have provided, to investigate me regarding any criminal records and to investigate my previous employment, educational background and references, and I release them from any liability and responsibility from doing so. Pursuant to section 31-128f of the Connecticut General Statutes, I also hereby release all parties supplying references and other personally identifiable information from any liability or damage whatsoever arising there from.

My volunteer application is not complete until I have read and signed the Background Verification Disclosure sheet that will be provided to me in a follow-up once this application is submitted.

The information supplied by me on this volunteer application is true and complete to the best of my knowledge. I understand that the discovery of any misrepresentation or omission of facts in the volunteer application may result in revoking my volunteer status.

My electronic signature below indicates my agreement and understanding of the above statements.

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