Junior Volunteer Application


Junior 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.

Last Name:
First Name:
Middle Name:
Previous Name, if any:
Present Address:
City, State, Zip:
Date of Birth:
Home#:
Cell#:
Email Address:
May we contact you via email? Yes No
Attending High School:
Phone#:
Expected Date of Graduation:
Emergency Contact:
Home#:
Address:
Relationship:
List two personal references, if possible (other than relatives):
Please include Name, Address and Phone#
Reference #1

Reference #2
Have you ever been convicted of a crime (other than minor traffic violations)? Yes No
If yes, please explain
(Conviction of a crime does not automatically disqualify you from consideration for volunteering; it is hospital policy to compare convictions to the service duties of the opportunities available)
Have you ever been used a name (i.e. nickname) other than the one listed on the volunteer application?
Yes No
If yes, what name?
Have you ever volunteered at another healthcare institution? Yes No
If yes, when and where?
Volunteer Electronic Signature (indicates you agree to the above):
Electronic Signature of Legal Parent or Guardian:

 

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