Adult Volunteer Application - Unicoi County Memorial Hospital


Home Address:

Skills and Interests

Special Skills (Ex: Photography):

Please list any previous volunteer experience:

Have you volunteered at a MSHA facility?*

Preferences in Volunteering

Is there a group with whom you are particularly interested in working? (Check all that apply)

Briefly explain why you are interested in volunteering:*


Are you required to volunteer? *


How did you hear about our Volunteer Program?

What type of recognition do you prefer? (check all that apply)*


At what times are you interested in volunteering? Many of our areas work in four hour shifts, but some areas require less time. (check all that apply)*

What days are you interested in volunteering? (Check all that apply)

Do you have any physical limitations which might limit your ability to perform certain types of work?*

Background Verification

Have you ever been convicted of a criminal offense?*


If you are considering volunteering as a Courtesy Cart driver, you must be a minimum of 18 years of age, have a current valid driver’s license, and have had no driving violations within the past 1 year.


I understand and agree that at no time will any information regarding patients of Mountain  States Health Alliance be revealed to anyone other than those authorized to receive it.  I understand that the giving of the information concerning a patient to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.

I agree to any necessary health screening required by the hospital and understand my volunteer assignment is contingent upon successful completion of this screening.  I UNDERSTAND I MUST HAVE A TB SKIN TEST ND FLU VACCINATION BEFORE I CAN BEGIN VOLUNTEERING.  The hospital will perform these at no charge to the volunteer. 

I understand that false statements made as a part of this enrollment may be considered sufficient cause for dismissal.

I authorize and consent for all named references and educational institutions or previous places of employment to release any personal and/or professional information about me to the MSHA Volunteer Office.  I also consent to a law enforcement record search and/or any other background investigation of me if chosen by the Volunteer Office.  I understand I have consented to these things as described herein, and in doing so, I further release, hold harmless, and indemnify Mountain States Health Alliance, the Volunteer Office, and any and all MSHA employees, officers, directors, and/or authorized agents, as well as those individuals or entities supplying such information about me, and/or conducting such search and/or investigation, from any liability, claims and/or causes of action as a result of any such inquiry, search and/or investigation.


v  I will abide by Mountain States Health Alliance’s general policy concerning patient confidentiality.

v  My assignment is on a probationary basis for a period of 60 days.

v  I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a result of my services, and MSHA is not legally liable for any worker’s compensation coverage or other similar benefits as a result of my services hereunder.

v  Photos taken while participating as a MSHA volunteer or at special functions may be used for promotional reasons.

v  I will observe all hospital regulations.



Submitting this form is your electronic signature and your acceptance of the Agreement above.

Do you agree to the statement above?*