APPLICATION FOR VOLUNTEER SERVICE

Warm Springs Medical Center

5995 Spring Street

Warm Springs, GA  31830

706-655-3331

Fax:  706-655-9233

DATE:_____________

PLEASE PRINT

NAME: ____________________________________________ SOCIAL SECURITY #: ______________________

ADDRESS:   ___________________________________________________________________________________

                             STREET                                                                  CITY                                               ZIP CODE

HOME TELEPHONE: _________________________BUSINESS TELEPHONE: _________________________

HOBBIES: 

REASONS FOR VOLUNTEERING:______________________________________________________________

OTHER HOSPITAL VOLUNTEER EXPERIENCE: 

REFERENCES   _______________________________________________________________________________________ NAME                                                                                                     PHONE #   _______________________________________________________________________________________ ADDRESS                                                                STATE                    ZIP CODE   _______________________________________________________________________________________ NAME                                                                                                    PHONE #   _______________________________________________________________________________________  ADDRESS                                                              STATE                    ZIP CODE

 

OCCUPATION: _________________________________ PREVIOUS EMPLOYER: _______________________

CURRENT EMPLOYER: _______________________________________________________________________

BIRTHDATE: ____________________ SINGLE:____________MARRIED:__________WIDOW:____________

PERSONAL/FAMILY DOCTOR: _________________________________________________________________

TYPING SKILLS: ______________________________________________________________________________

IN CASE OF AN EMERGENCY NOTIFY

_____________________________________________________________________________________________________

NAME                                                                     RELATIONSHIP                                     PHONE#

VOLUNTEER APPLICATION (con't.)

Warm Springs Medical Center

 I AM INTERESTED IN THE FOLLOWING AREA (S):

___ Information Desk/Switchboard

___ Hospitality Cart

___ Nursing Home Activities                               

___ Other __________________________________  

Permission for criminal background check _______yes _______no

STATEMENT OF RESPONSIBILITY

                If accepted as a volunteer at Warm Springs Medical Center, I pledge to hold in strict confidence, all personal and official matters that come to my attention. It is my responsibility to respect and preserve the privacy of the patient as well as any details involved.

STATEMENT OF UNDERSTANDING

                I authorize Warm Springs Medical Center to write or phone my references whom I have listed and release Warm Springs Medical Center and anyone releasing this information to Warm Springs Medical Center from any liability based upon such release. I understand that my volunteer assignment is based upon appropriate availability, skills, and needs of Warm Springs Medical Center. Should Warm Springs Medical Center find that I am not suited to the assignment or my performance is unsatisfactory I understand that my assignment as a volunteer may be terminated without further explanation.

                In case of accident or injury, I specifically release the hospital and all others from any liability or other obligation.

___________________________________________

Signature

HOW WERE YOU REFERRED TO WARM SPRING MEDICAL CENTER?

_________FRIEND         ________ NEWSPAPER AD        _______ FAMILY     ___________OTHER

FOR OFFICE USE ONLY:

	Revised 07/19/2004