logo
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

    • OCTOBER 3, 2019
    Outreach Programs Help Patient Learn to Live with Cancer

    Outreach Programs Help Patient Learn to Live with Cancer

    Donna Harris, 52 of Pikeville, was diagnosed with stage 3 colorectal cancer in early December of 2018. It would take some time for her to learn how to live with it She had been noticing for months that she was having an upset stomach, nausea and extreme fatigue. She visited her long-time physician, PMC Primary

    Read more
    • APRIL 1, 2019
    PMC’s New Technology Detects Breast Cancer Earlier and Provides Less Invasive Biopsies

    PMC’s New Technology Detects Breast Cancer Earlier and Provides Less Invasive Biopsies

    Pikeville Medical Center (PMC) advances breast cancer detection with the addition of new state-of-the-art equipment. The use of the Hologic 3 Dimensions Mammography, BK Flex Focus 400 In-office Breast Biopsy and Hologic Stereotactic Biopsy focuses on two specific areas of breast care, the detection of abnormalities at microscopic levels and less invasive biopsies. “The growing

    Read more
    • MARCH 11, 2019
    PMC Receives Accreditation for Cancer Program

    PMC Receives Accreditation for Cancer Program

    Pikeville Medical Center (PMC) was recently awarded the 2018 Outstanding Achievement Award by the Commission on Cancer (CoC) of the American College of Surgeons (ACS).  PMC is part of an elite group of health care facilities, which includes 24 U.S accredited cancer programs to receive this national honor for cancer surveys performed Jan. 1 –

    Read more
    • NOVEMBER 5, 2018
    PMC Able to Target Radiation Directly to Surface of Skin Cancer

    PMC Able to Target Radiation Directly to Surface of Skin Cancer

    Pikeville Medical Center (PMC) today announced it has adopted the Xoft® Axxent® Electronic Brachytherapy (eBx®) System®, an advanced technology able to deliver a targeted dose of radiation directly to the surface of nonmelanoma skin cancer (NMSC) lesions. The Xoft System is FDA cleared for the treatment of cancer anywhere in the body, including early-stage breast

    Read more

About Us

Our mission is to advance the health and well-being of our region through comprehensive care in a Christian environment.

Our vision is to be the provider and employer of choice for healthcare in the region we serve.

Click here to learn more about our mission, vision and values.


MyChart Login

MyChart Signup Without Activation Code

MyChart Signup With Activation Code

MyChart User Guide

Download MyChart for iOS

Download MyChart for Android

Important Links



Terms of Use

Filing a Grievance, Concern or Comment

Patient Rights and Responsibilities

HIPAA Notice of Privacy Practices

Nondiscrimination and Accessibility Notice

Federal and Kentucky Labor Law Postings

Corner Market Online Gift Shop

FacebookTwitterYouTubeYouTube
Translation Services
© 2013-2022 Pikeville Medical Center, all rights reserved.
Pikeville Medical Center