STUDENT APPLICATION

__________Date Application Received

__________Orientation Notice Sent
__________Orientation Date
__________ Interview Date/Time
__________Reference Requests Mailed
Ref #1 Ref #2 Ref #3

NAME (Mr. Mrs. Miss Ms.)___________________________________________________________________

Last First Middle Intial
ADDRESS_____________________________________________________________________________

CITY_____________________________________________________STATE_______ZIP____________

E-MAIL ADDRESS______________________________________________________________________

PHONE NUMBER(S): Home___________________________Work_______________________________

DATE OF BIRTH________________________SOCIAL SECURITY NUMBER_____________________

(month/day)

Are you a U.S. citizen or, if not, do you have a current alien registration receipt card? _____no ____yes

EMERGENCY CONTACTS:

_______________________________________________________________________________________
(Name and Relationship) (Home Phone) (Work Phone)

_______________________________________________________________________________________
(Nearest Relative) (Home Phone) (Work Phone)

_______________________________________________________________________________________________
(Name of physician) (City) (Phone)

EDUCATION:
____________________________ High School _____________________________College Degree

____________________________Certification _____________________________Other Training

VOLUNTEER EXPERIENCE: (School, Agency, Hospital, Other)_____________________________________

_______________________________________________________________________________________

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HOW DID YOU HEAR ABOUT OUR PROGRAM?

Newspaper____ Church____ Brochure_____ School_____ Friend____ Own Initiative____ Other ____

If referred by a Moffitt Volunteer, please let us know who to thank:____________________________

Have you volunteered for Moffitt before? (if yes, when)__________________________________________

Have you ever been convicted of a felony, entered a plea of guilty to a felony charge, entered a plea of
no contest to a felony charge or have you ever had an adjudication withheld?

NO________ YES_______
If yes, please explain:__________________________________________________________________

INFORMATION FOR SERVICE AREA PLACEMENT:

1. Do you have any physical limitations that would affect your volunteer placement such as bad back, poor
hearing, or poor vision, etc? Yes No

If yes, please explain:_________________________________________________________________

2. Are you able to volunteer at least 4 hours a week? Yes No

Day and time availability _______________________________________________________________

3. Would you be willing to work on special projects? Yes No

REQUIRED PERSONAL REFERENCES:

1. Personal references are required for all volunteer files. Reference forms will be provided at the volunteer
orientation.

EMPLOYMENT:
Current or last place of employment ____________________________________________________

Employer Contact________________________________________ Phone___________________________

Have you ever been discharged or asked to resign by an employer: _____No_____Yes, please explain:

___________________________________________
SPECIAL SKILLS:
___Accounting ___Data Entry ___Mechanical
___Art Work ___Escort/Transport ___Musical (instrument/vocal)
___Bookkeeping ___Filing ___Organizing
___Calligraphy ___Fundraising ___Patient Care
___Carpentry ___Infant/Childcare ___Phone Receptionist

G:\Volunteers\Website info\Student orientation Packet info\College Student application.doc

___Cashiering ___Journalism ___Proofreading
___Communications ___Listening ___Public Relations
___Computer Work ___Marketing ___Teaching

LANGUAGES:

___Arabic ___Greek ___Japanese ___Swedish

___Chinese ___Hebrew ___Polish ___Vietnamese
___French ___Indian ___Russian ___Other________
___German ___Italian ___Spanish

VOLUNTEER AGREEMENT
(Please initial after reading the statements below)
___ As an H. Lee Moffitt Cancer Center volunteer I agree to uphold the values of the organization by
providing a high standard of quality service to our patients and staff.
___ I agree to hold, absolutely confidential, all information that I may obtain directly or indirectly
concerning patients, doctors, or personnel.
___ I can be depended on to work my assigned shift and will call, in advance, if not able to fulfill that
obligation.
___ I will wear the proper uniform as outlined in the orientation packet.
___ I understand that I will be expected, before placement, to complete the Volunteer Training Program
and required TB screening.

ACKNOWLEDGEMENT AND AGREEMENT:

I acknowledge that I have read and understand the statements above. The information provided in this
application is true in all respects without any willful omissions. I authorize H. Lee Moffitt Cancer Center to
obtain a personal reference and background check. I understand that if this application is false in any way I
will be dismissed without notice regardless of when the false information is discovered.

Signature:_____________________________________ Date:________________________________
YOUR SIGNATURE INDICATES YOUR APPROVAL FOR US TO CHECK REFERENCES AND CONTACT YOUR PHYSICIAN REGARDING YOUR
PHYSICAL AND EMOTIONAL HEALTH. THE ORGANIZATION IS NOT OBLIGATED TO PROVIDE A PLACEMENT, NOR ARE YOU OBLIGATED TO
ACCEPT THE POSITION OFFERED. A VOLUNTEER POSITION DOES NOT CONSTITUTE AN EMPLOYEE-EMPLOYER RELATIONSHIP WITH THE
CANCER CENTER.

OPPORTUNITIES FOR VOLUNTEERS ARE PROVIDED WITHOUT REGARD TO COLOR, RACE, RELIGION, AGE, CREED, NATIONAL ORIGIN, SEX,
DISABILITY, VETERAN OR MARITAL STATUS. H. LEE MOFFITT CANCER CENTER REASONABLY ACCOMMODATES INDIVIDUALS WITH
DISABILITIES.

G:\Volunteers\Website info\Student orientation Packet info\College Student application.doc

 Short Essay

In the space below, please answer the following questions:

What do you want to gain from volunteering at Moffitt?

What will make you a successful, dependable volunteer?

G:\Volunteers\Website info\Student orientation Packet info\College Student application.doc

Letter of Intent
For college student volunteers
I understand that becoming a Moffitt Cancer Center volunteer involves a commitment
of 3-4 hours per week for two semesters. This equates to 36+ hours per semester or
75 hours of service.

I understand that the reason for this minimum commitment is due to considerable
hospital resources dedicated to the volunteer on-boarding process. This process
includes screening, background checks, TB/health screening, photo ID badge,
orientation, screening, training, placing, training, and supervising volunteers. This is
provided at no cost to me.

The dependability of volunteers directly impacts the quality of service provided to the
patients. Students who are reliable will be invited to participate in unique patient care
areas.

With this in mind, I have considered my obligations to school, work, and other extra-
curricular activities. If accepted as a volunteer at Moffitt Cancer Center, I pledge to
contribute three to four hours per week for two semesters.

Signed: ___________________________________ Date: _________________

 Confidential
Reference
Form for
Volunteer

___________________ has submitted an application to volunteer at the H. Lee Moffitt Cancer

Center & Research Institute and has given your name as a reference. We are seeking volunteers
who are self-motivated, dependable, and can provide excellent service to our patients and staff.
Please complete the survey below so that we can determine if the applicant will be a good
candidate for our volunteer program. All reference forms can be given to the volunteer
candidate so that they can return it to our office, or faxed to (813) 745-2810, or mailed to the
address below. All information you provide will be confidential. Thank you.

H. Lee Moffitt Cancer Center

Volunteer Services – MCC-VES
12902 Magnolia Dr.
Tampa, FL 33612-9497
How long have you known the applicant? _________________________________________

In what capacity have you known the applicant? ____________________________________

__________________________________________________________________________
Describe the applicant's reliability and willingness to make a commitment such as this:
___________________________________________________________________________
__________________________________________________________________________
Are you aware of any physical or emotional problems that would limit the applicant’s ability to
perform required duties?
__________________________________________________________________________
Would you recommend the applicant for placement in a health care setting such as ours?
___________________________________________________________________________
Or, do you feel the applicant is better suited for another type of volunteer agency?
___________________________________________________________________________
Additional comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________
Please print your name:_________________________Signature:_______________________
Date: __________________________
 Confidential
Reference
Form for
Volunteer

___________________ has submitted an application to volunteer at the H. Lee Moffitt Cancer

Center & Research Institute and has given your name as a reference. We are seeking volunteers
who are self-motivated, dependable, and can provide excellent service to our patients and staff.
Please complete the survey below so that we can determine if the applicant will be a good
candidate for our volunteer program. All reference forms can be given to the volunteer
candidate so that they can return it to our office, or faxed to (813) 745-2810, or mailed to the
address below. All information you provide will be confidential. Thank you.

H. Lee Moffitt Cancer Center

Volunteer Services – MCC-VES
12902 Magnolia Dr.
Tampa, FL 33612-9497
How long have you known the applicant? _________________________________________

In what capacity have you known the applicant? ____________________________________

__________________________________________________________________________
Describe the applicant's reliability and willingness to make a commitment such as this:
___________________________________________________________________________
__________________________________________________________________________
Are you aware of any physical or emotional problems that would limit the applicant’s ability to
perform required duties?
__________________________________________________________________________
Would you recommend the applicant for placement in a health care setting such as ours?
___________________________________________________________________________
Or, do you feel the applicant is better suited for another type of volunteer agency?
___________________________________________________________________________
Additional comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________
Please print your name:_________________________Signature:_______________________
Date: __________________________
 AUTHORIZATION FOR VOLUNTEER BACKGROUND REPORT
This document is provided in compliance with the Consumer Credit Reform Act of 1996, and the amended Fair Credit
Reporting Act, and in support of Moffitt Cancer Center’s completion of a background screening program.

I hereby authorize H. Lee Moffitt Cancer Center & Research Institute, and its designated agents and representatives to
conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be
generated for volunteer purposes.
I understand that the scope of the consumer report/investigative consumer report may include, but is not
limited to the following areas:
Verification of social security number; current and previous residences; employment history including all
personal files; education; character references; credit history and reports; criminal history records from any
criminal justice agency in any or all federal, state, county jurisdictions; birth records; motor vehicle records to
include traffic citations and registration; and any other public records.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration
and law enforcement agencies) to divulge any and all information, written or verbal, pertaining to me to H. Lee Moffitt
Cancer Center & Research Institute or its agents. I further authorize the complete release of any records or data pertaining to
me which the individual, company, firm, corporation, or public agency may have, to include information or dates received
from other sources.
I hereby release H. Lee Moffitt Cancer Center & Research Institute, the Social Security Administration, and its agents,
officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and
collectively, from any and all liability for damages of whatever kind, which may, at any time result to me, my heirs, family, or
associates, because of compliance with this authorization and request to release. You may contact me as indicated below.
I understand this authorization automatically expires 90 days from the date executed below and that I have the right to revoke
the authorization at anytime, provided I do so in writing.
Please print clearly.

Name:_____________________________________________________________________________________________________
(Last) (First) (Middle) (Maiden)

Former Name(s) and Dates Used:_______________________________________________________________________________

(Names) (Dates Used)
Please check one: ( ) Female ( ) Male

Please check one: ( ) Single ( ) Married

Please check one: ( ) White ( ) Black ( ) Hispanic ( ) Asian ( ) American Indian

Please check all that apply: ( ) Vietnam Era Veteran ( ) Disabled Veteran
( ) Disabled Individual (indicate type of disability): __________________________________
( ) Visual ( ) Hearing ( ) Chronic Illness ( ) Mobility ( ) Other

Please list all home addresses that you have had in the last five years:

Current ___________________________________________________________________________________________________
(Since:Mo/Yr) (Street) (City) (Country) (State) (Zip)

Previous __________________________________________________________________________________________________
(Since:Mo/Yr) (Street) (City) (Country) (State) (Zip)

Previous __________________________________________________________________________________________________
(Since:Mo/ Yr) (Street) (City) (Country) (State) (Zip)

Social Security # _________________________________________ Date of Birth: ____________________________

Signature: ______________________________________________________ Date: ____________________________