Adult Volunteer Application Form
Please complete this application form if you are interested in becoming a Baptist Memorial Desoto Hospital volunteer. Once you complete the form, click the submit button at the bottom.
Name and address
First name:
*
Last name:
*
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
*
Street 2:
Street 3:
City:
*
State:
Choose
MS
TN
*
Zip:
*
Home phone:
*
OK to call me here
Work phone:
OK to call me here
Email address:
Demographic Information
You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
(year optional)
Age:
Gender:
Choose
Female
Male
*
Education:
Choose
Associate degree
College degree
Doctoral degree
High school
Masters degree
Some college
Trade/Vocational school
School:
Availability
Please indicate the days and times you are usually available to volunteer.
Mon
Tue
Wed
Thu
Fri
Morning:
Afternoon:
Evening:
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
Please provide any information you feel would be pertinent to volunteering at Baptist DeSoto
Email Preferences
We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.
What kinds of email would you like to receive?
Electronic newsletters
Recruitment appeals
Checklist reminders
Previous Volunteer Experience
Please list any previous volunteer experience
Please list any previous volunteer experience you may have
References
Please provide 2 references(non family members)
1
2
Employer name:
Employer name:
First name:
*
First name:
*
Last name:
*
Last name:
*
Street 1:
*
Street 1:
*
City:
*
City:
*
State:
Choose
MS
TN
*
State:
Choose
MS
TN
*
Zip:
*
Zip:
*
Home phone:
*
Home phone:
*
Work phone:
Work phone:
Emergency Contact Information
First name:
*
Last name:
*
Home phone:
*
Cell phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
*
Volunteer Agreement
The above information is correct and accurate to the best of my knowledge. My signature indicates that I approve for the above references to be checked. The Volunteer Services Department is not obligated to provide a placement nor am I obligated to accept the position offered. Opportunities are provided for volunteers without regard to religion, creed, race, national origin, age or sex.
I understand that volunteering services in hospital settings is not without risk or exposure to disease, including, but not limited to, Human Immunodeficiency Virus (AIDS), Hepatitis B, and other communicable infectious diseases. However, with training, which will be provided as part of the orientation program, and strict adherence by the volunteer to that training, exposure to and risk of contracting disease can be reduced. Understanding this, the undersigned expressly assumes the risks of participating in the volunteer program and releases and discharges Baptist Memorial Hospital, Baptist Memorial Health Care System, Inc., their affiliates, and their agents and employees, from any and all liabilities or claims arising from or related to the exposure to or contraction of any disease(s), ailment(s), or condition(s) as a result of participation in the volunteer program at Baptist Memorial Hospital.
I acknowledge that, in the event that I become ill or am injured as a result of my participation in the volunteer program, I will not be covered by any employment-related insurance coverage such as worker’s compensation, although my health benefits obtained from personal sources may provide coverage. Additionally, I agree that if I am injured or become ill as a result of my participation in the volunteer program, all related costs for medical treatment or associated costs are my responsibility and are not the responsibility of Baptist.
I Agree
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