Volunteer Application Form

Personal Information

(111) 111-1111
(111) 111-1111

Home Address:

mm/dd/yyyy

Emergency Contact:

(111) 111-1111

What areas are you interested in working in?







SCHEDULE PREFERENCE

Day(s):






Indicate Shift(s):




We ask for a minimum required service of 100 hours (50 hours for the summer) or more.

EXPERIENCE

Past Volunteer Experience:

Please tell us more about one of your previous volunteer experiences:

Employment Experience:

(111) 111-1111
mm/dd/yyyy

Past employer:

mm/dd/yyyy

REFERRAL SOURCE

EDUCATION

mm/dd/yyyy
mm/dd/yyyy
Download Volunteer Reference Form fill the details and select the updated form using below select field and submit the  form.
Upload the Volunteer Reference Form

I certify that all responses on this document are true to the best of my knowledge.  I agree that this information may be verified and references contacted by the DMC Volunteer Services.  This will include Michigan State Police and Public Sex Offenders Registry checks.  I understand that any misrepresentation of information constitutes cause for separation or termination from service.

DMC - Rehabilitation Institute of Michigan

Confidentiality Agreement

In consideration for volunteer’s access to the DMC/Rehabilitation Institute of Michigan and its various facilities, volunteer agrees as follows:

1.   Volunteer will follow the procedures set forth by the DMC/Rehabilitation Institute of Michigan to register himself/herself with RIM Volunteer Services prior to his/her service.

2.   Volunteer agrees to be in proper uniform and dress code and to keep his/her DMC Identification visible during the course of his/her engagement.

3.   Volunteer agrees to remain in assigned areas only, unless authorized or accompanied by  appropriate DMC personnel.

4.   Volunteer understands that he/she may come in contact with “protected health information” as that term has been defined by the Health Insurance Portability and Accountability Act.  Volunteer agrees that he/she will not at any time, either during his/her engagement or thereafter, copy or record that information, or use for his own benefit or divulge, furnish or otherwise make available, either directly or indirectly to any person, firm, corporation or other entity any proprietary or protected health information. Volunteer shall keep all privileged patient-related information strictly and absolutely confidential. This involves no conversation in any public areas such as elevators, parking structure, cafeteria, hallways, etc.

5.   I understand that I may be given access codes or passwords to DMC computer systems. I will safeguard the codes and passwords.  I am prohibited from disclosing my security codes to anyone including family, friends and other DMC employees.

6.   Volunteer, upon the cessation of their engagement or upon termination of service with the DMC will immediately surrender and deliver to the DMC all lists, books, records, memoranda, documents, data, uniforms and ID of every kind relating to proprietary or protected health information and all other property belonging to the DMC.

7.   I understand that failure to comply with any of the stated requirements could be cause for termination, revocation of privileges and access to the DMC.  It could result in notice to my educational institution, my agency or employer.

8.   Signed form must be on file at the Rehabilitation Institution of Michigan Volunteer Services, 261 Mack, Detroit, MI 48201, Office - (313) 745-1149, Fax (313) 745-9327, before start of service.