Meadowlands Hospital Medical Center
Volunteer Office
55 Meadowlands Parkway
Secaucus, NJ 07094

Dear Friend:

Thank you for inquiring about our Meadowlands Hospital Volunteer Program. Attached are a Release Authorization form and an Application for you to fill out and return via mail or email or fax it to my attention at 201-392-3527.

To ensure the safety of our patients, staff and volunteers, Meadowlands Hospital requires any applicant over the age of 18 to a background screening. A 3-hour orientation session is also required for all volunteer applicants. Once all requirements have been satisfied, you will be cleared to begin volunteering. At that time; hours and availability will be discussed.

The orientation consists of a tour of the hospital and a general overview of Meadowlands Hospital Medical Center and our Volunteer Program.

Volunteers at our facility perform countless valuable services including working on units ensuring patients' comfort or helping staff members in various departments. It is our mission to achieve the hospital's continuing goal to provide the best possible health care to the communities we serve.

We welcome you to join us!

Sabina Sanchez

Community Services Department

Meadowlands Hospital Medical Center


Please list two references (friend, physician, clergy, employer; PLEASE NO FAMILY MEMBERS OR ANYONE WHO LIVE WITH YOU) who we may contact:

Have you ever been convicted of a felony or serious crime?

Are you interested in direct involvement with patients?

Please circle any of the following in which you are skilled:

Actual commitment time will be determined during the interview and orientation.

I understand that any misleading or false statements, or subsequently discovered material omissions would be cause for immediate dismissal after starting volunteering. I understand that my volunteering is contingent upon receipt by this organization of satisfactory references. I will notify Volunteer Services if I an unable to keep my volunteer assignment. I agree to abide by the requirements and regulations of Meadowlands Hospital Medical Center and the service to which I am assigned. I will keep in confidence all information I may hear concerning a patient, doctor, employee, or volunteer.


Meadowlands Hospital Medical Center


Meadowlands Hospital Medical Center



Have you ever had or do you presently have: YES NO EXPLAIN
Breathing Problems (asthma, emphysema, etc.)
High or Low Blood Pressure
Heart Problems/Poor Circulation
Back Problems
Hearing Problems
Visual Problems (glasses, glaucoma, cataracts)
Nervous Condition
Chronic Illness (diabetes, epilepsy, etc.)
History of any surgery
History of any work related injury
Are you taking any medications?

Were your results significant? Yes No


Have you ever had or been vaccinated or tested for? YES NO EXPLAIN
German Measles (Rubella) (documentation required)
Measles (Rubeola) For those born after 1956 (documentation required)
Chicken Pox (Varicella)
Any other contagious disease

I certify that the above information is accurate and complete to the best of my knowledge.

Date Signature

Parent/Guardian Signature

Disclosure and Release

Meadowlands Hospital may obtain information about you from a 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. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your criminal history, education and/or employment history conducted by Accutrace, Inc. P.O. Box 624, Bryn Mawr, PA 19010 or by contacting us at 1-888-54 -TRACE or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment is limited to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly.

Acknowledgment And Authorization
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Accutrace, Inc. or another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ("fax") or photographic copy of this Authorization shall be as valid as the original.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.
Please Print Clearly

Date of Birth (mm/dd/yyyy)
Driver's License No.
Professional License/Certificate Number
School/University Name
Degree/Diploma Type
Date Received

Current Address

Previous Addresses within the Past 7 Years
Current Address

Current Address

Para informacion en espanol, visite o escribe a la
FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave.
N.W., Washington, D.C. 20580.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
- a person has taken adverse action against you because of information in your credit report;
- you are the victim of identify theft and place a fraud alert in your file;
- your file contains inaccurate information as a result of fraud;
- you are on public assistance;
- you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to

• You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information, visit States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

Federal enforcers are:


Consumer reporting agencies, creditors and others not listed below:
Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580

National banks, federal branches/agencies of foreign banks (word "National" or initials
"N.A." appear in or after bank's name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219

Federal Reserve System member banks (except national banks, and federal
branches/agencies of foreign banks)
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551

Savings associations and federally chartered savings banks (word "Federal" or initials
"F.S.B." appear in federal institution's name)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552

Federal credit unions (words "Federal Credit Union" appear in institution's name).
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314

State-chartered banks that are not members of the Federal Reserve System
Federal Deposit Insurance Corporation
Consumer Response Center,
2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638

Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or
Interstate Commerce Commission
Department of Transportation
Office of Financial Management
Washington, DC 20590

Activities subject to the Packers and Stockyards Act, 1921
Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250