Volunteer Sign Up

JEFFERSON REGIONAL MEDICAL CENTER IS AN EQUAL OPPORTUNITY EMPLOYER. NO QUESTIONS ON THIS APPLICATION ARE ASKED FOR THE PURPOSE OF LIMITING OR EXCLUDING ANY APPLICANT’S CONSIDERATION FOR VOLUNTEER SERVICE BECAUSE OF RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, SEXUAL ORIENTATION, DISABILITY, OR VETERAN STATUS.

Download and complete the paper application or complete the email form below.

Personal
Experience
(hobbies or interests)
Volunteer Interest
WE SHALL ASSIGN YOU ACCORDING TO AVAILABILITY, INTERESTS, SKILLS AND OUR NEEDS. CHECK ASSIGNMENT(S) WHICH APPEAL TO YOU.
Medical Information
PERSON TO CONTACT IN CASE OF EMERGENCY
AT THE PRESENT TIME, IS THERE ANY PHYSICAL CONDITION WHICH COULD LIMIT PARTICIPATION IN THE VOLUNTEER PROGRAM? IF YES, EXPLAIN.
Background
IF YES, please provide dates. Note that Jefferson Regional Medical Center was formerly St. Joseph's Homestead Hospital and South Hills Health System (SHHS).
IF YES, PLEASE PROVIDE POSITION. INCLUDE POSITIONS WITH ST. JOSEPH'S HOMESTEAD HOSPITAL OR SOUTH HILLS HEALTH SYSTEM (SHHS).
HAVE YOU EVER BEEN CONVICTED OF, PLEADED GUILTY TO, OR ENTERED A PLEA OF NOLO CONTENDERE (NO CONTEST) TO ANY VIOLATION OTHER THAN A SUMMARY OFFENSE.
HAVE YOU EVER ACCEPTED ACCELERATED REHABILITATIVE DISPOSITION (ARD), PROBATION WITHOUT VERDICT (PWV) OR A SIMILAR COURT MONITORED PROGRAM OTHER THAN A SUMMARY OFFENSE?
Reference #1
Reference #2
Applicant's Signature
I CERTIFY THAT ALL STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT, MISREPRESENTATION OR OMISSION MAY CAUSE MY DISMISSAL FROM VOLUNTEER SERVICE.

Jefferson Regional Medical Center
565 Coal Valley Road
Jefferson Hills, PA 15025
412-469-5000

Physician Referral:
412-469-7000

Community Programs:
412-469-7100

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