Volunteer Application

Mission

Madonna Rehabilitation Hospitals are Catholic hospitals that provide physical medicine and rehabilitation services to children and adults throughout the nation. We rehabilitate those who have sustained injuries or disabling conditions so they can fully participate in life; lead research to improve outcomes; and prevent physical disabilities and promote wellness through community programs.

Core Values

Madonna Rehabilitation Hospitals are dedicated to the healing ministry of Christ. In the spirit of our Catholic heritage and Benedictine traditions, we commit ourselves to the Core Values of:

Collaboration Hospitality Respect Innovation Stewardship Teaching

Volunteer

Applying for:

Year Round Volunteer
Temporary Volunteer

Which location are you applying to be a volunteer?

Lincoln Campus
Omaha Campus

First Name *

Last Name *

Middle Initial *

Title *

Preferred Name *

Phone *

Email *

Address *

City, State *

Zip Code *

Birthday *

Emergency Contact Person

Relationship

Emergency Contact Phone

Students Complete This Section

School Attending

Area of Study

Are you seeking to complete a school requirement for volunteer services?

If yes, please describe

Total Hours Required

Date of Deadline for completion of service

Education, Employment and Volunteer Experience

Complete High School or GED

Have you ever been employed by Madonna Rehabilitation Hospitals?

If yes, in what capacity?

Are you currently employed?

if so, who is your employer and what is your occupation?

Have you volunteered at MRH in the past?

If so, in what capacity?

Are you currently involved in volunteer activities elsewhere?

If so, for which organization(s) and position(s)?

Please list any previous volunteer or paid employment experience.

Skills/Preferences (check all interests)

Helping Visitors/Families
Helping Patients
Helping Residents (Lincoln Campus)
Mailings/Special Projects
Office/Clerical
Sewing/Crafts
Other

Please check the boxes for the days you are most often available to volunteer.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please check the boxes for the times you are most often available to volunteer

Morning
Afternoon
Evening

Have you ever lived in or traveled to a country with widespread Ebola virus transmission or had contact with an individual with confirmed Ebola virus

Have you ever been convicted of a crime (i.e., misdemeanor or felony)?

If yes, please explain and include dates.

Do you have any family members who are employed by Madonna?

If yes, please specify.

Do you need verification of your Madonna volunteer hours for a requirement?

If yes, please explain.

How Did you Hear About our Volunteer Program?

I hereby authorize Madonna Rehabilitation Hospitals to investigate the statements made in this application to contact all employers, schools, character references, governmental agencies, law enforcement agencies, health and human services and the state patrol and police department in order to obtain information on my background and history. I agree to sign consent forms if requested so that a full background and history can be obtained. I further agree and affirm that if there are any changes in my criminal history or any involvement with health and human services from the time I sign this application, I will provide updated information, in writing, to Madonna Volunteer Resources.

I understand that any false, misleading or incomplete responses in this application will be sufficient cause for not becoming a volunteer.

I will read the Volunteer Handbook prior to my start date and am responsible for understanding and adhering to the Madonna Volunteer Resources policies.

Volunteer Signature

Date

Please enter the word *

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