VCU Volunteer Data Form

VCU Volunteer Data Form

PREFIX

Select or enter value

VOLUNTEER’S NAME

(LAST NAME, FIRST NAME, MIDDLE IN

SUFFIX

DATE OF BIRTH

HOME ADDRESS STREET

APT #

CITY

STATE

Select

ZIP CODE + 4

HOME PHONE

BUSINESS PHONE

CELL PHONE

EMAIL ADDRESS

EMERGENCY CONTACT

EMERGENCY CONTACT NAME

EMERGENCY CONTACT'S HOME PHONE

EMERGENCY CONTACT'S BUSINESS/CEL

EMERGENCY CONTACT'S HOME ADDRESS: STREET

EDUCATION

EDUCATION: COLLEGE ATTENDED

MAJOR

YEAR

Criminal History

Have you ever been convicted of a misdemeanor or a

Select

If yes, please explain:

Heading

I will be volunteering with:

Name of Department

REFERENCE #1 NAME

REFERENCE #1 HOME PHONE

REFERENCE #1 BUSINESS/CELL PHONE

REFERENCE #1 HOME ADRESS:STREET

REFERENCE #1 APT#

REFERENCE #1 CITY

REFERENCE #1 STATE

Select

REFERENCE #1 ZIP CODE + 4

REFERENCE #2 NAME

REFERENCE #2 HOME PHONE

REFERENCE #2 BUSINESS/CELL PHONE

REFERENCE #2 HOME ADDRESS: STREET

REFERENCE #2 APT NUMBER

REFERENCE #2 CITY

REFERENCE #2 STATE

Select

REFERENCE #2 ZIP CODE + 4

I hereby agree to volunteer with Virginia Commonwealth University (VCU). I understand that, as a volunteer, I have the right to say no to any task asked of me with which I feel uncomfortable.

I acknowledge and understand that I may have access to confidential information regarding employees, students, patients or the public, or to proprietary or other confidential business information belonging to VCU. In addition, I acknowledge and understand that I am required to comply with all applicable federal, state, and university policies, procedures and regulations, including those related to the use of university funds or resources.

Therefore, except as required by law and excluding information that can be released under federal, state, or university regulations, I agree that I will not:

• Access data that is unrelated to my assigned duties at VCU;

• Disclose to any other person, or allow any other person access to, any information related to VCU that is proprietary or confidential.

Disclosure of information includes, but is not limited to, verbal discussions, FAX transmissions, electronic mail messages, voice mail communication, written documentation, “loaning” computer access codes and/or any other transmission or sharing of data.

I understand that VCU and its employees, students, patients or others may suffer irreparable harm by disclosure of confidential or proprietary information and that VCU may seek legal remedies available to it should such disclosure occur. I understand that failure to comply with applicable policies, procedures and regulations may result in a loss of resources and that VCU may seek legal remedies available to it should such losses occur. Further, I understand that violations of this agreement may result in dismissal from my volunteer assignment.

Signature: *

By clicking this button, you agree to all terms and conditions established by Virginia Commonwealth University, the VCU School of Nursing, and any affiliated departments within the VCU School of Nursing with which you are collaborating.

Date*

Virginia Commonwealth University – Volunteer Program

Revised April 2013

Created June 2008

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