Mercy Valley
Medical Center
Volunteer Services

Volunteer Application

Auxiliary & Patient Support

Our volunteers help patients and families feel cared for from the front door onward. Because you'll be in a clinical setting, this application includes the health and confidentiality clearances every Mercy Valley volunteer completes.

A

Applicant information

Priya Nadkarni
July 22, 1990
(480) 555-0124
44 Sycamore Lane, Mesa, AZ 85204
B

Placement & availability

Information & Wayfinding Desk
Weekday mornings
Weekday afternoons
Weekends
C

References

NameRelationshipPhone
Dr. Helen Okafor
Former supervisor
(480) 555-0177
Marcus Lee
Volunteer coordinator
(480) 555-0150

Required clearances & acknowledgments

Immunization & TB clearance. I agree to complete Mercy Valley's required health screening — including a two-step TB test and proof of immunization (MMR, varicella, and seasonal influenza) — before my first shift, and I understand placement is contingent on clearance from Employee Health.

Background check consent. I authorize Mercy Valley Medical Center to conduct a criminal background check and verify the references above as part of my volunteer application.

HIPAA confidentiality agreement. I understand I may encounter protected health information and I agree to keep all patient and hospital information strictly confidential, in accordance with HIPAA and Mercy Valley policy, during and after my service.

Nathan Cole
Applicant signature
June 18, 2026