Please complete this application form if you are interested in becoming a Southview Medical Center volunteer. Please note that all applicants must consent to and undergo a criminal background check which will be coordinated by Kettering Health. Once you complete the form, click the "Continue" button at the bottom.


*Indicates required information fields.

**Note: All volunteers are required to have a TB screening blood test, employee health evaluation and a yearly flu shot.


NAME AND ADDRESS


PROFILE INFORMATION

Social Security Number and Date of Birth are required and used for background checks which must be completed prior to beginning your volunteer service.



BACKGROUND

Have you ever pled guilty to, been convicted of, been released without imposition of sentence, or received pretrial diversion for any crime?


If YES, describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates and their disposition. Conviction of a crime is not an automatic ban for consideration for volunteer opportunity.


If "NO", please type NO.


Falsification and non-disclosure of information will result in rejection of application or termination of volunteering.



EMERGENCY CONTACTS

In case of an emergency, please list two individuals we can contact on your behalf.



ASSIGNMENT INTEREST

Please indicate the type of volunteer work preferred.



AVAILABILITY

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



REASON FOR VOLUNTEERING


Signature

By clicking "I Agree", I verify that all disclosed and non-disclosed information on the application is correct and true, and I authorize Southview Medical Center to perform the required background check.