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.

First Name:
Middle Name:
Last Name:
Previous Name,if any:
SSN:
Are you between the age of 14 and 17?	Yes No
Month/Day of Birth:
Home #:
Cell #:
Present Address:
May we contact you by e-mail?	Yes No
E-mail Address:
Attending High School:
Phone #:
Expected Date of Graduation:
Shirt Size:
Emergency Contact:
Name:
Relationship:
Phone #:
Address:
I/We hereby agree to allow our son/daughter to serve as a Junior Volunteer at Pikeville Medical Center. I/We fully understand that during the course of his/her duties or son/daughter may be permitted to enter patient areas of the Medical Center.
E-Signature of Parent/Legal Guardian:
Date:
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?
I (volunteer) have never been convicted of a criminal offense related to health care nor have I ever been listed as debarred, excluded, or otherwise ineligible to participate in federal health care programs. We certify that all the information furnished in this application is true and complete to the best of our knowledge. We understand and give authorization to Pikeville Medical Center’s Volunteer Services Department to investigate the information, call the above work and/or personal references listed, and conduct OIG, GSA and OFAC investigations to determine volunteer status.
Volunteer Signature:
Date:
Parent/Legal Guardian Signature:
Date:
CONSENT FOR MINOR TO PARTICIPATE IN VOLUNTEER ACTIVITIES I hereby authorize and consent for , a minor, to participate in such volunteer activities at Pikeville Medical Center (hereinafter “PMC”) from time to time as may be directed by the Hospital’s Director of Volunteer Services or their designated representative. I understand that volunteer services are donated to PMC without compensation or promise of future employment, and are donated for humanitarian, religious, charitable, or other altruistic reasons. I hereby further release and hold harmless PMC and its officers, agents, directors, and employees from any and all claims of liability for any damages, injury or illness resulting to the aforementioned minor while participating in such volunteer activities. I hereby authorize and confer consent to PMC to render any and all medical treatment and care to that is deemed advisable by, and is to be rendered under the general or direct supervision of any physicians and/or surgeon on the PMC medical staff, whether or not such care is to be rendered in the physician’s office or at PMC. This authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority to PMC to allow any and all such diagnosis, treatment, or hospital care which said physician, in the exercise of independent medical judgement, may deem advisable. I hereby agree that will comply with PMC’s vaccination policy, including any authorizations to release his/her protected health information or otherwise apply for an appropriate exemption, and that failure to comply with PMC’s vaccinations policy may prevent from being accepted as a volunteer, or may lead to his/her dismissal as a volunteer.
Signature of Parent or Legal Guardian
Relationship to minor:
Witness:
Date: