Auxiliary Council of Richland Memorial Hospital Volunteer Services Application Form

Richland Memorial Hospital may conduct a detailed and thorough investigation, which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

Last Name *

First Name *

Middle Name (full)

Social Security Number *

Are you a U.S. citizen or an alien legally authorized to work in the U.S.?

Yes
No

Street Address *

City, State Zip *

Home Phone *

Alternate Phone or Cell

E-Mail

Best Time to Contact You *

Best Time for You to Work *

How Did you Hear About our Volunteer Services?

Please mark the volunteer positions you are most interested in filling (all that apply):

Gift Shop
Surgical Waiting Room
Patient Escort
Long Term Care
Office Helper

First Preference (from above) *

Have you volunteered your time or services with another organization? If yes, where?

Briefly describe duties and skills gained through previous volunteerism?

Have you ever been convicted of, or plead guilty to, a crime (excluding misdemeanor traffic violations)?*

Yes
No

If yes, please explain:

Have you ever been involved in the substantiated abuse or neglect of children or an adult under the laws of this or any other state of the United States?*

Yes
No

If yes, please explain:

* If you answered “yes” to either of the above, you will not automatically be disqualified from being considered as a volunteer, except as required by State or Federal Law or the policies of Richland Memorial Hospital concerning employment.

REFERENCES

Reference 1 - provide the Name and Relationship, Title, Company Name and Telephone Number.

Reference 2 - provide the Name and Relationship, Title, Company Name and Telephone Number.

Reference 3 - provide the Name and Relationship, Title, Company Name and Telephone Number.

CAREFULLY READ THIS SECTION PRIOR TO SUBMITTING THIS FORM

I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading repre-sentations or omissions made on the application may disqualify me from further consideration as a volunteer and may result in discharge even if discovered at a later date.

I understand that my eligibility to volunteer my be conditioned upon successfully passing a TB test and that I may be required to complete a drug screening as a condition of volunteerism.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application, and I completely release all such persons or entities from any and all liability related to the providing or use of such formation.

I understand my volunteerism is at-will which means that I may terminate the relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the pre-ceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.