Adult Volunteer Application

- OCTOBER 14, 2022
October Brings Heightened Awareness to Breast Cancer
Statistics show that one in eight women will be diagnosed with breast cancer in her lifetime. Each October is recognized as Breast Cancer Awareness Month, and the staff of the Lawson Cancer Center at Pikeville Medical Center takes this time to encourage the importance of having mammograms. “Regular screenings are important because, with them, we
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- OCTOBER 7, 2022
Lawson Cancer Center Specialists Using Cutting-Edge Technology
The Lawson Cancer Center at Pikeville Medical Center is using innovative technology to treat patients whose treatment plans call for radiation therapy. In 2021, PMC installed a state-of-the-art TrueBeam Linear Accelerator from Varian Medical Systems, which allows radiation oncologists at the Lawson Cancer Center to deliver radiation treatments more accurately than ever before. “At the
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- OCTOBER 29, 2021
Cancer Clinical Trials Close to Home
Cancer is a scary diagnosis that many patients throughout Eastern Kentucky and Central Appalachia face daily. Pikeville Medical Center (PMC) is dedicated to providing advanced cancer care, eliminating the need for patients to travel outside the region as much as possible. The PMC Leonard Lawson Cancer Center is among a relatively small percentage of cancer
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- APRIL 16, 2021
Plastic Surgery Can Help Restore Self-Esteem for Breast Cancer Patients
When many people think of plastic surgery, their minds automatically see images of face lifts, tummy tucks or a variety of other cosmetic options. However, Pikeville Medical Center (PMC) Plastic and Reconstructive Surgeon, Dimitrios Danikas, MD, FACS also spends time with women who are battling breast cancer to plan and perform reconstructive surgery. According to
Read more

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

October Brings Heightened Awareness to Breast Cancer

Lawson Cancer Center Specialists Using Cutting-Edge Technology

Cancer Clinical Trials Close to Home

Plastic Surgery Can Help Restore Self-Esteem for Breast Cancer Patients

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