Adult Volunteer Application - Unicoi County Memorial Hospital
Skills and Interests
Special Skills (Ex: Photography):
Please list any previous volunteer experience:
Preferences in Volunteering
Briefly explain why you are interested in volunteering:*
How did you hear about our Volunteer Program?
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.
I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER:
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.