VOLUNTEER RECORD

(To be completed by the University and maintained in the Department)

Department Name	

Volunteer Name 	

Assignment Beginning Date 		End Date 	

Description of services to be rendered on a volunteer basis*:

	

Name of supervisor for patient care activities: 	

Volunteer Schedule		Monday			Thursday		
		Tuesday			Friday		
		Wednesday 			Saturday		

Location where volunteer assignment will be performed:  [   ] Campus   [   ] Medical Center   [   ] Other

Building name and room number:	
	(please give specific information)

(To be completed by the volunteer)

Name 	

Address 	

Home telephone 		Work telephone 	

If a student, name of school 	

In case of emergency, contact:

Name 		Relationship to volunteer  	

Day telephone 		Evening telephone  	

The volunteer service described above will be uncompensated. I understand that either the University or I may discontinue the volunteer service at any time without notice. I agree to abide by all rules and policies of the University.

Volunteer 	Date

University Representative & Title	Date

*Services should not include contact with human blood, body fluid or tissue, radioactive compounds or hazardous chemicals without prior consultation with Environmental Health and Safety to ensure the volunteer has the appropriate training, vaccinations and health coverage.