Adult Volunteer Application

- OCTOBER 18, 2024
PMC Encourages Breast Cancer Awareness And Screenings
October is Breast Cancer Awareness Month and health experts are reminding women of the critical importance of early detection in the fight against breast cancer. In the United States, breast cancer remains the most common cancer among women, with one in eight women facing a diagnosis in her lifetime. Early detection significantly improves the chances
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- OCTOBER 18, 2024
PMC Offers Region’s Only Board Certified Breast Radiologist
At Pikeville Medical Center, women can screen for breast cancer with confidence knowing that Board Certified Breast Radiologist Dr. Cherah Pryce is among the medical experts reviewing their screening results. Dr. Pryce specializes in diagnosing breast cancer and provides expert imaging evaluation of 3D mammograms, breast MRIs, breast ultrasounds and stereotactic-guided biopsies. “A breast radiologist
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- AUGUST 20, 2024
Colors of Courage 5K Brings Hope to Patients and the Community
Runners and walkers are lacing up their shoes for the ninth Colors of Courage 5K Run/Walk to raise money to support cancer patients of the Lawson Cancer Center at Pikeville Medical Center. The Colors of Courage 5K is one of the most popular running/walking events in downtown Pikeville and will be held on the morning
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- AUGUST 19, 2024
Lawson Cancer Center Providing Comprehensive Oncology Care
The Lawson Cancer Center (LCC) at Pikeville Medical Center (PMC) provides healing and comfort for individuals and families navigating the challenging journey of a cancer diagnosis and treatment. Patients at the LCC receive comprehensive care, personalized treatment and unwavering support from the entire oncology team, which embraces a multidisciplinary approach to cancer care. This group
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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:

REFERENCES

Latest News and Events

PMC Encourages Breast Cancer Awareness And Screenings

PMC Offers Region’s Only Board Certified Breast Radiologist

Colors of Courage 5K Brings Hope to Patients and the Community

Lawson Cancer Center Providing Comprehensive Oncology Care

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