AHN Pet Therapy Volunteer Application

* First name

* Family/last name

* Address Line 1

Address Line 2

* City

State

* Zip/postal

* Phone (Home)

Gender

Requested site

Were you previously a volunteer within the Allegheny Health Network?

I confirm that I am 16 years of age or older.

I confirm that I am 18 years of age or older.

I confirm that I have a valid social security number.

Pet Therapy Questions

App: Have you been certified as a therapy team?

* App: Name of certification as a pet therapy team?

* App: Where and when did you receive you certification?

Availability

Days and Hours Available

Sunday

8am-Noon

Noon-5pm

5pm-9pm

Monday

8am-Noon

Noon-5pm

5pm-9pm

Tuesday

8am-Noon

Noon-5pm

5pm-9pm

Wednesday

8am-Noon

Noon-5pm

5pm-9pm

Thursday

8am-Noon

Noon-5pm

5pm-9pm

Friday

8am-Noon

Noon-5pm

5pm-9pm

Saturday

8am-Noon

Noon-5pm

5pm-9pm

* Why did you select Allegheny Health Network?

Skills, Hobbies, or Interests

History

Work/Volunteer Experience

Experience Date Range

Type of Experience

Are you related to any employee or staff member of the Allegheny Health Network?

* If yes, list the name of the employee, your relationship to that person, and the department in which they work

Have you ever been employeed by the Allegheny Heath Network?

* If so, when and where?

Are you required to perform court-ordered community service?

Have you ever been convicted of a felony?

* If so, describe in full. (A past conviction does not necessarily prevent you from being considered for volunteer work.)

References

Please list two professional/character references (supervisor of paid/volunteer work, clergy, teacher).

* Reference 1 name

Relationship

* E-mail

* Phone

* Reference 2 Name

Relationship

* E-mail

* Phone

Emergency Contact

* In case of emergency, notify: Contact name

* Relationship

Phone (Home)

Phone (Mobile)

Agreement

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief and have been given voluntarily. I understand that Allegheny Health Network requires certain information both personal and professional from me to evaluate my qualifications and consider me for volunteer services. I understand that in consideration of my application, a background investigation may be conducted. I hereby grant Allegheny Health Network permission to verify such answers and investigate all references, and conduct such further investigation as is necessary, including, but not limited to, the performance of medical examinations, drug screening, reference verification, military service verification, and criminal background checks. I understand that any false statements or incomplete information on this application may be considered sufficient cause for rejection of this application or for dismissal if such information is discovered subsequent to my volunteer work. I authorize any past and present employers, personal references, and other organizations, to answer all questions asked concerning my previous employment and/or volunteer record, ability, character, educational background, military service, or criminal history. I hereby release all employers, persons or organizations, from any liability whatsoever for providing this information. I understand that I may be asked to discontinue my volunteer services at any time for any reason. I understand that Allegheny Health Network will not be responsible for any personal injury or property loss that may occur to me while performing volunteer services. I understand that I will not receive any monetary compensation from Allegheny Health Network, individual employees or anyone else for serving as a volunteer. I hereby agree to abide by all policies and procedures of Allegheny Health Network. I will treat information regarding patients and employees in strict confidence. By submitting this application I agree with the Applicant's Certification.

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