For Patients


For Physicians

   

Volunteer Application Form

Give Back and Help Shape Your Community

Volunteering at Pacific Hospital of Long Beach plays an important role in the healing of patients and assisting their families. Serving others is a special gift and we are searching for those who will serve patients in all areas.

Thank you for your interest in volunteering at PHLB and helping give back to your community. Please fill out the form below and we will get back to you shortly.

VOLUNTEER APPLICATION FORM - PLEASE COMPLETE AND WE WILL GET BACK TO YOU

 * Required

FIRST NAME *

  

LAST NAME *

  

EMAIL *
         

STREET ADDRESS *

  

CITY + STATE *

  

ZIP CODE *
         

HOME PHONE *

  

BUSINESS PHONE

  

OTHER PHONE
         

EMERGENCY CONTACT *

  

RELATIONSHIP *

  

PHONE *

EXPERIENCE, SKILLS & INTERESTS (Tell us about yourself!)

How did you become interested in volunteering with PHLB?  How did you become interested in volunteering with PHLB?


Please list previous volunteer experience, organizations, professional societies or any other relevant information.  Please list previous volunteer experience, organizations, professional societies or any other relevant information.


Are you volunteering to earn hours for a school or education program?  Are you volunteering to earn hours for a school or education program?


 		 – If yes, please describe: 


Do you read, speak or write a language other than English?  Do you read, speak or write a language other than English?


 		 – If yes, list languages: 

If yes, would you be interested in interpreting for patients/visitors? 


Do you have any physical limitations or medical conditions you may have that would prevent you from performing certain types of work?  Do you have any physical limitations or medical conditions you may have that would prevent you from performing certain types of work?


 		 – If yes, please list: 

There are job criteria and physical requirements for each position.
We will try our best to assign you to a position that will accommodate your skills or limitations while mutually benefiting you as well as the hospital.


In what areas are you most interested in volunteering?  In what areas are you most interested in volunteering?

Please indicate your preference of hours for volunteering.  Please indicate your preference of hours for volunteering.

 8:00a to 12:30p:       
12:30 p to 4:30p:       


May we contact you to assist with special projects such as Health Fairs?  May we contact you to assist with special projects such as Health Fairs?


THREE REFERENCES (Please do not list relatives)

NAME * PHONE NUMBER * HOW LONG HAVE YOU
KNOWN THIS PERSON? *

AGREEMENT

  • I understand any misrepresentation or material omission of information in this application may be a cause of dismissal from the Volunteer Services of Pacific Hospital of Long Beach.
  • I understand that there are job criteria for positions. We will try our best to accommodate your skills, limitations, etc. to assign you to an available position that will be mutually beneficial to you and Volunteer Services of Pacific Hospital of Long Beach.
  • I understand that state & national hospital regulatory agencies require that persons working in a hospital setting receive orientation/training each year and have an annual TB test. Failure to do so may results in temporary suspension from the Volunteer Services until completed.
  • I agree to read & abide by the policies and procedures, expectations, ethics, customer service standards as presented in the “Volunteer Handbook” and orientation and to perform the duties expected of me to the best of my ability.

CERTIFICATION (Must be completed in order to submit application!)

 I hereby certify that all the information included on this application is true and complete to the best of my knowledge.