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.
 
 
 

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


 
 
 
 
 
 

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





 

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)?**


 

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?**


 

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.