Beebe Auxiliary Application

One way to volunteer is to be an Auxiliary Volunteer.

The mission of the Auxiliary is to raise resources to support the programs and projects of the Medical Center. Founded in 1936, this group is Beebe Healthcare's oldest fund raising organization.

Once your application has been received, please check your email to complete the necessary next steps. This will include scheduling a phone interview session and orientation to discuss your interests with the Auxiliary.

Once the orientation has been attended, an assignment is given and volunteering can begin.

Personal Information

Please provide the following information so we can contact you. Please note, you must be at least 14 years old to volunteer.

First name:

Last name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Date of birth:

* (year optional)

Shirt/Vest Size:

Today's Date:

Have you ever been convicted of, or plead guilty to a crime other than a misdemeanor or traffic violation?, If no, state No. If yes, please explain. An answer must be provided or application cannot be processed.

Volunteer Information

Why Beebe? Please let us know why you have chosen Beebe to volunteer and what you are interested in doing.

Have you previously served as a volunteer at Beebe Medical Center? If so, when and where.

Are there any other organizations that you volunteer with?

Availability

Please let us know what your availability would be so we can better match an opportunity for you.

Interests

Please share any special interests you may have.

Personal References

List at least two (2) references who are not relatives.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Email address:

Auxiliary/Fundraising

The following volunteer opportunities require that you join the Auxiliary first. Please note that there is an annual fee of $10 for membership.

Emergency Contact Information

Please provide the name, address and telephone number of someone that we can contact in case there is an emergency.

First name:

Last name:

Home phone:

ALL PERSONS SEEKING VOLUNTEER PLACEMENT:

WITH A HEALTH CARE FACILITY ARE REQUIRED TO READ AND SIGN THIS ACKNOWLEDGEMENT. THIS IS ACCORDING TO THE STATE OF DELAWARE REGULATIONS: Special Employment Practices Regulations Relating to Health Care Facilities (19 Del. C. 708 and 11 Del. C. 8563 and Adult Abuse Registry Check (11 Del. C. 8564)

*****************************

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of Delaware or any other state in the United States? Please answer YES or NO. If yes, please explain:

Please answer these two questions. An answer must be provided or application cannot be processed.

Disclaimer

Are you, or have you ever been, subject to exclusion or debarment under Federal law, or designated in a state abuse registry (including any nurse aid registry) as having a finding concerning abuse, neglect, mistreatment or misappropriation of property? Please answer YES or NO. If yes, please explain:

CAREFULLY READ THIS PRIOR TO SIGNING BELOW:

I authorize a full release for Beebe Medical Center to obtain information from my current and/or previous employer(s). I attest that the information I have given on the application (and accompanying resume, if any) represents a full and complete disclosure of information about my employment history, and that all information contained in the volunteer application is true and complete to the best of my knowledge and belief. I understand that failure to provide a full and complete disclosure is a violation of the law and, as such, is subject to civil penalties in the form of a fine. I understand that any false or misleading representation or omission made on the application during the volunteer interview process may disqualify me from further consideration for volunteering and may result in discharge even if discovered at a later date.

I understand that volunteering is conditional upon successfully passing the Adult, Child Abuse Registry and Criminal background check. Understand that should my position require it, Beebe Medical Center may obtain a copy of my driving record.

I understand that my volunteering is at-will which means that I may terminate the volunteer relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

I Agree