Welcome to the Sparrow Hospital Volunteer Services Department

Adult Referred Volunteer Application

College Student Volunteers - Do Not Use this Application: Sparrow has a partnership with MSU to coordinate all college student volunteers, regardless of where they attend. College students need to register through the MSU Service Learning & Civic Engagement. Please visit their web site at http://www.servicelearning.msu.edu/students/would-you-like-to-volunteer-at-a-hospital. If you have further questions, please call 517.353.4400.
Volunteer Contact Information
Referrer's name
First name
Middle name
Family/last name
Address/Apartment #
City
State
Zip/postal
Home phone
Work phone
Mobile
Fax
E-mail
Emergency Information (Person to be notified in the event of an Emergency)
Contact name
Address
City
State
Zip/postal
Home phone
Mobile
Pager
Educational Information
High School
Graduate?
Business College/Vocational Training
Graduate?
College/University
Graduate?
If yes, where:
Are you attending classes now?
Work Experience
Employer 1:
Name of Organization
Job Title
Date Worked From
Date Worked To
Employer 2:
Job Title
Name of Organization
Date Worked From
Date Worked To
Employer 3:
Name of Organization
Job Title
Date Worked From
Date Worked To
Volunteer Experience
Volunteer Organization 1:
Volunteer Organization
Date Volunteered From
Date Volunteered To
Volunteer Organization 2:
Volunteer Organization
Volunteer Position
Date Volunteered From
Date Volunteered To
What/who has motivated you to seek volunteer opportunities at Sparrow?
Describe your Patient/Family experience at Sparrow.
Which Sparrow department(s) and/or locations(s) did you or your family member receive services?
Please share your ideas or suggestions for improvement
Choice of Volunteer Position
First Choice
Second Choice
Third Choice
Indicate times you are available to volunteer
How long do you anticipate being available to volunteer?
Years
Months
How many times per month would you be interested in serving?
What do you want to achieve from your volunteer experience?
Miscellaneous
Have you ever been convicted of a misdemeanor or felony?
If yes, please explain
Are you volunteering to satisfy court ordered service?
Do you use nicotine products?
Nicotine-free Volunteer Policy Statement
To further our mission in providing quality, compassionate care to everyone, every time, effective April 1, 2012, Sparrow Health System will no longer offer volunteer placements to potential volunteers who use tobacco or nicotine products in any form. Sparrow promotes a healthy and safe environment for all Associates, Physicians, Volunteers, Patients and Visitors.

A nicotine user is any individual who uses nicotine products including, but not limited to, cigarettes, cigars, pipes and chewing tobacco. This policy also applies to e-cigarettes, which are regulated by the Food and Drug Administration as a nicotine product. Nicotine patches and gum are also included.
I hereby willingly consent to the completion of a background investigation and authorize Sparrow and/or its agents to request from any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, any records or information pertaining to me. I further authorize any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, to divulge any and all information, verbal or written, pertaining to me, including information or data received from other sources to Sparrow and/or its agents.

It is my understanding that any information obtained in the course of the background investigation will be held strictly confidential by Sparrow and its agents. Information gathered will be used only in connection with the volunteer placement process. I hereby authorize Sparrow and/or its designated agents and representatives to conduct a comprehensive review of my background, which may include information concerning my criminal, motor vehicle, and other history.

I understand this authorization automatically expires 90 days from the date executed below and that I have the right to revoke this authorization at any time, provided I do so in writing to Sparrow.
Full Name (First, Middle, Last)
Have you had a name change within the last seven years?
Please list any other name(s) used in the last seven years
Date of Birth
My typed name shall have the same force and effect as my written signature
Date