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:

Street 1:

Street 2:

Street 3:

City:

State:

* 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:

(year optional)

Age:

Gender:

Education:

School:

Availability

Please indicate the days and times you are usually available to volunteer.

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:

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Emergency Contact Information

First name:

Last name:

Home phone:

Cell phone:

Relationship:

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