Adult Volunteer Application Form

Today's Date:*

First Name:*

Last name:*

Middle Name:

Street Address:*

City:*

State:*

Zip Code:*

Home Phone:*

Work Phone:

Email:*

I am 18 years of age or older*YesNo

If presently employed, provide name of firm (if retired, please list last employer)*

Position:

Work hours and days:

Days you are able to volunteer:*

Time of day you can volunteer:*

In case of emergency, contact

Name:*

Address:*

Home Phone:*

Work Phone:

How did you become interested in our volunteer program?

Have you volunteered or worked for McCullough-Hyde before?YesNo

Have you ever been convicted of a misdemeanor or felony?YesNo

Please give any other information you feel may be pertinent to your application

Personal or professional references (please do not use relatives)

1. Name:*

Phone:*

Address:*

Email:

2. Name:*

Phone:*

Address:*

Email:

Are you interested in:*Clinical with patients areaNonclinical without patients area

Are you interested in:*Weekly positionSubstitute positionAs needed position

Interests / Skills

Please indicate which areas/duties you would be willing to share as a volunteer here.

Additional skills, hobbies or comments

The information I provided is accurate and correct to the best of my knowledge.*

I understand that my signature indicates approval for MHMH to perform a background check and/or request fingerprints. Please be aware that McCullough-Hyde Memorial Hospital, Inc. is not obligated to provide volunteer placement, nor are you obligated to accept a position.

Electronic Signature:*

Today's Date:*

Opportunities for volunteers are provided without regard to creed, race, national origin, age or sex. *State Senate Bill 187 requires us to notify you that you may at any time be subject to a criminal records check. McCullough-Hyde is a smoke free and tobacco free campus. This position is not an employee position and is not paid for the services rendered. Influenza vaccines are mandatory and documentation should be submitted to volunteer services by November 1 of each year. TB testing (tuberculosis) is required before volunteering. This can be done in our Immunology Clinic free of charge. Call 513.524.5566 for hours. Also, a copy of your immunization records (showing MMR and Hepatitis B) will be collected from you before volunteering.