VS Pre-Approved Volunteer Application

New User Details

User ID

User ID (verify)

Password

Password (verify)

PRE-APPROVED VOLUNTEER APPLICATION

Required Fields are marked with an asterisk (*)

Volunteer Information

* First Name (Legal)

M.I.(use NA if no M.I.)

* Last Name (Legal)

UMID Number

* Local Address

Apt #

* City

State

* Zip/Postal

* Permanent Address

Apt #

* City

State

Zip/postal

Country

* Phone- Cell (XXX)XXX-XXXX

Alternate Phone if no cell (XXX)XXX-XXXX

Sex

* Date of Birth (MM/DD/YYYY)

*Is Applicant a Minor? You must be at least 18 years of age to apply.

Citizenship

Race and Ethnicity

If you are a Michigan Medicine employee, please upload a photo of your MCard.

Visa Information

Check if you are in the U.S. on a Visa

Visa Type (Please select)

Visa - other

Visa Exp. Date

NOTE: Please upload a copy of your visa with at least one form of supporting documentation.

Visa (Upload image)

Visa Supporting Documentation such as I 20, I 94, or DS 2019 forms.

Emergency Contact Information

* Emergency Contact Name First/last (Local)

* Relationship

* Primary Phone Number (XXX)XXX-XXXX

* Emergency Contact Name First/Last (Family)

* Relationship

* Primary Phone Number (XXX)XXX-XXXX

Criminal Records Check Information

Have you ever been convicted of a crime or misdemeanor?

Are there any felony charges pending against you?

Is there anything in your history you want to tell us before we run your criminal background check? If yes, please describe below.

Placement Information

* Department

* Department Head

* Pre-Approved Placement

* Department Campus Address

* Department Phone (XXX)XXX-XXXX

* Primary Pre-Approved Supervisor Name - list only one name

* Pre-Approved Supervisor Email - list only one email

* Pre-Approved Supervisor Telephone

* Volunteer's Work Location (Building and Room)

* *Description of Volunteer Duties (Please be specific ESPECIALLY about patient contact)

* Work with Patients, Clients, Blood, Other

NOTE: Work with Patient/Client means "in the room" with Patients/Families/Study Participants/Clients/Members.

Lab/Research/Med Student/Intern/Practicum (Click all that apply)

If this is a Practicum/Internship/Preceptorship, will you be receiving course credit, monetary or other compensation for this placement?

Proposed Schedule

* PA Appointment Start Date

* PA Appointment End Date

Note: Maximum 1 year (Annual Update required if extending past 1 year)

* Scheduled Weekday(s), Time(s)

Note: Minimum 40 hrs or 90 days, whichever comes first

Certification

I certify that my answers are true and complete to the best of my knowledge. I agree that this information has been verified and references may be contacted by Michigan Medicine Volunteer Services. I authorize the University of Michigan Health System, through the Department of State Police Central Records Division, the University of Michigan Department of Public Safety and Security or any agency to conduct criminal history check or investigation by name and identifiers to determine the existence of any arrest resulting in conviction and furnish a response to Michigan Medicine. Misrepresentation of facts constitutes cause for separation from Volunteer Services.

* (check box for agreement)

* Type Your Full Name

* Date: (XX/XX/XXXX)

NOTE: This application expires in 30 days. If the volunteer applicant does not respond to required onboarding actions, the application must be resubmitted to Volunteer Services.