Menu
Become a Volunteer Graphical header

Adult Volunteer Application

Pikeville Medical Center offers opportunities to all men, women and young people to serve as volunteers without restriction regarding race, national origin, religion, financial status, disabilities, sex or age.

First Name:
Middle Name:
Last Name:
Previous Name,if any:
SSN:
Are you 18 or older? Yes No
Month/Day of Birth:
Home #:
Cell #:
Present Address:
May we contact you by e-mail? Yes No
E-mail Address:
If employed, Name or Organization:
Work Phone #:
Have you ever been employed by PMC? Yes No
If yes, when?
Have you ever lived in any other state? Yes No
If yes, which state(s)?
Shirt Size:
Emergency Contact:
Name:
Relationship:
Phone #:
Address:

REFERENCES


List two personal references, if possible (other than relatives):
Reference #1 Name:
Reference #1 Address:
Reference #1 Phone:
Reference #2 Name:
Reference #2 Address:
Reference #2 Phone:
Have you ever been convicted of a crime (other than minor traffic violations)? Yes No
If yes, please explain:
(Conviction of a crime will not automatically disqualify you from consideration for volunteering; it is a hospital policy to compare convictions to the service duties of the opportunities available.)
Have you ever used a name other than the one listed on the volunteer application? Yes No
If yes, what name?
Have you ever volunteered at another health care institution? Yes No
If yes, where and when?
I certify that the information given by me in this application is true in all respects and I agree that if accepted as a PMC volunteer and it is found to be false in any way, I may be subject to dismissal without notice. I authorize the use of any information in this application to verify my statements and I authorize the past employers, doctors, and all references, and other persons to answer all questions asked concerning my ability, character, and reputation. I release all such persons from any liability or any damages on account of having furnished such information.


I represent and warrant that I am not now nor have I ever been (i) listed by an agency or entity as excluded, debarred, suspended, or otherwise ineligible to participate in any federal, state, or private health care benefit program; (ii) listed as an excluded party by the U.S. Department of Health and Human Services or general Services Administration; (iii) been charged with, convicted of, pled guilty to, or entered a plea of nolo contendere (or any similar plea) with respect to any health care-related offense; or (iv) been sanctioned for any form of health care fraud or abuse. I will notify PMC immediately upon the commencement of any proceeding against me in which the outcome may be any of the above-described events.


I authorize such background and personal reports as are deemed necessary to verify that the information I have supplied is true and accurate. A copy of this authorization is as valid as the original.


If accepted as a volunteer and I appear to be unfit for duty due to suspected influence of alcohol or other drugs or if I am involved in an accident or safety incident, I may be subject to further drug screening or face termination of volunteer status. I hereby authorize any physician, laboratory, hospital, or medical professional retained by Pikeville Medical Center to both conduct such screening and provide the results thereof to Pikeville Medical Center, and I release Pikeville Medical Center, its agents, employees, and such institution or person(s) from liability therefore.

I further agree to execute any documentation necessary to comply with PMC’s vaccination policy, including any authorizations to release my protected health information or otherwise apply for an appropriate exemption. I agree that before I can be accepted as an adult volunteer I must comply with PMC’s vaccination policy and failure to comply may lead to me not being accepted as a physician shadow or being dismissed as an adult volunteer.



I understand that all Volunteer applicants with Pikeville Medical Center will be required to complete a drug and alcohol test prior to the final acceptance date. I understand and give authorization to Pikeville Medical Center to conduct that following checks: personal references, OIG, GSA, OFAC, Sexual Offender Registry and Criminal Background.

Volunteer Signature:
Date:

 

>>><<<

Latest News and Events

    • DECEMBER 20, 2022
    PMC Receives 2023 Women’s Choice Award as One of America’s Best Hospitals for Cancer Care

    PMC Receives 2023 Women’s Choice Award as One of America’s Best Hospitals for Cancer Care

    Range of treatment services, low infection rates cited in award recognition Pikeville Medical Center (PMC) has been named one of America’s Best Hospitals for Cancer Care by the Women’s Choice Award®, America’s trusted referral source for the best in healthcare. The award signifies that PMC is among the top U.S. hospitals offering cancer care services.

    Read more
    • OCTOBER 28, 2022
    Lawson Cancer Center Features On-Site, Dedicated Oncology Pharmacy

    Lawson Cancer Center Features On-Site, Dedicated Oncology Pharmacy

    Patients who are treated either as an inpatient or in the outpatient clinic setting at the Lawson Cancer Center at Pikeville Medical Center can rest assured knowing their complex chemotherapy medications are prepared in an exclusive on-site oncology pharmacy. Having an oncology pharmacy within the facility dedicated solely to mixing and preparing chemotherapy for all

    Read more
    • OCTOBER 25, 2022
    The Importance of Cancer Screenings

    The Importance of Cancer Screenings

    Screening for cancer can save lives. Cancer screenings are conducted in attempts to find cancer at early stages, oftentimes before symptoms are prevalent. It is important to speak to a primary care physician about which tests are needed and at what age. Primary care doctors can also discuss risk factors, such as family history and

    Read more
    • OCTOBER 21, 2022
    Clinical Trials and a Team Approach

    Clinical Trials and a Team Approach

    The Lawson Cancer Center at Pikeville Medical Center has various multidisciplinary teams to evaluate and treat its patients. All Lawson Cancer Center staff—from nurses and patient navigators to specialty physicians—work together with each patient to develop an individualized treatment plan. “At PMC, we have many subspecialists in oncology,” said PMC Hematologist/Oncologist Dr. Dinali. “Our medical

    Read more
Pikeville Medical Center