MyMichigan Health College Volunteer Program

Personal Information

Requested site

* First name

Middle name

* Family/last name

* Please list any other last names used (maiden, alias, etc.) A responce is required, if none, you must type NONE:

* DOB (MM/DD/YYYY)

Gender

* Street Address

Apartment/Suite No. or P.O. Box

* City

State

* Zip/postal

* Preferred Phone Number

Phone (Mobile)

Phone (Work)

E-mail (if you do not have an email address, please leave this field blank)

Background Information

Have you ever been a volunteer for MyMichigan Health

Have you ever been employed by MyMichigan Health?

If Yes, please list dates of service:

Have you ever been convicted of a crime other than a traffic offense?

If yes, please explain:

Volunteer Information

Volunteer type

School Name

Program of Study

* Date available to begin:

How frequently would you like to volunteer and do you have preferred days of the week?

Emergency Contact Information

* Name of Person to Notify (First & Last Name):

* Relationship (spouse, parent, friend, etc.):

* Phone (Home)

Phone (Mobile)

Phone (Business)

Applicant Statement

I acknowledge that the information I have supplied is correct to the best of my knowledge and understand that any deliberate falsifications, misrepresentations or omissions of fact may be grounds for rejection of my application or dismissal from the volunteer program. I understand that consideration for volunteer placement is contingent upon the results of reference, screening for TB and background checks including a criminal check. I therefore authorize MyMichigan Health to invesitgate all statements made on my application and to discuss the results of the investigation with those responsible for volunteer selection and placement. If accepted for volunteer placement, I will comply with the values, policies and procedures of MyMichigan Health in effect or revisions which may be issued in the future. Misrepresentation of facts constitutes cause for separation from volunteer placement. I understand that the position that I am applying for is an unpaid volunteer position.

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

MyMichigan Health (the Company) may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report is an employment history or verification. These searches will be conducted by Universal Background Screening, Inc., Post Office Box 5920, Scottsdale, AZ 85261, 1-877-263-8033, www.universalbackground.com. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.

* Please type your name to agree to the application statement: