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NORTHCREST MEDICAL CENTER
Volunteer Services
100 NorthCrest Drive Springfield,
TN
37172 (615) 382-5743 |
Volunteer Application Form
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The information on this form will help us to find the
most satisfying and appropriate volunteer service for you. Your cooperation in completing
it is appreciated. |
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Legal Name:
Last
First
Middle |
Address
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If Presently Employeed,Name of Firm
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Position
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Work Hours & Days
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Contact In Case of Emergency:
(Name)
(Relationship) (Home Phone)
(Work Phone) |
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Family Physician
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Phone
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Limitations Related to Health
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How did you become interested in our Volunteer Program?
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Have you volunteered for this organization before?
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Education (Select last year completed)
Grade:
HighSchool:
College: |
Volunteer Experience
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Work Experience
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Indicate Hobbies/Skills/Special Interests/Foreign or Sign Language Skills:
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Please give any other information you feel pertinent to your application.
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When would be the best time for you to volunteer (Please select you choice.)
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When would be the best days for you to volunteer. (Please select your choice.)
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REFERENCES: Please choose your references from among the following: friend, minister,
employer, current volunteer at NorthCrest Medical Center. (NOTE: Any of these references
should be non-family members.)
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1.NAME
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Phone:
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Address
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2.NAME
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Phone:
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Address
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| VOLUNTEER AGREEMENT |
I hereby express my intention and desire to participate in the NorthCrest Medical Center Volunteer Services Program.
I understand that it is my responsibility to read the rules and regulations of NorthCrest Medical Center Auxiliary Handbook/Bylaws and the job description of my volunteer assignments. I agree to abide by these regulations and to perform my assigned volunteer duties to the best of my ability.
I understand that any offer of volunteer opportunities at NorthCrest Medical Center will be conditional upon verification of my references, attendance at a general orientation program, and any other requirements specified by NorthCrest Medical Center and the NorthCrest Medical Center Auxiliary.
By submitting this application, I authorize NorthCrest Medical Center or its representatives to investigate and verify any and all of the information contained in this application, including a criminal background check and inquiry into the GSA and OGI sanction list. I also authorized all references listed herein to verify any and all information I have provided and to give any additional information in response to reference questions intended to determine my suitability for volunteering. I hereby release all investigators, individuals and NorthCrest Medical Center from any liability for providing or receiving such information.
I wish to donate my services to the hospital, and I understand that at no time shall there exist an employer-employee relationship between myself, as a volunteer, and the hospital.
I further understand confidentiality must be maintained on patient and family information. |
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