OUR PURPOSE, OUR PROMISE - To make a positive difference in every life we touch

Thank you for your interest in volunteer opportunities at Piedmont Athens Regional. Please complete this application form in it's entirety. Once you complete the form, click the Continue button at the bottom.

Name and Contact Information

First name:

Last name:

Middle name:

Nickname:

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Address

Street 1:

Street 2:

City:

State:

* Zip: *

Mailing Address (if different from above)

Previous Volunteer Experience

Please enter the Names & addresses of the organization, the duties performed and the timeframe that you volunteered.

Why Volunteer at Piedmont Athens Regional

Please share your reasons for wanting to volunteer at Piedmont Athens Regional Hospital.

Employment History

Please list your work experience below, beginning with the most recent position. All information must be completed in full.

1

2

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

3

4

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

References

PLEASE DO NOT LIST RELATIVES. All information must be completed in full.

1

2

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Cell phone:

3

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Cell phone:

Emergency Contact

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Other phone:

Relationship:

Applicant's Certification (Please read carefully)

I understand that if I am chosen to be a volunteer, it will be my responsibility to:

Complete an orientation program scheduled for new members and attend service area training in my specific service area before beginning service;

Complete mandatory annual educational requirements;

Provide proof of immunity to Measles, Mumps and Rubella;

Complete Turberculosis screening process with re-testing done annually (provided free to Volunteers);

Wear a volunteer badge when working at the hospital;

Fulfill my assignments and hours obligations because the hospital staff and patients depend on me; and

If I am unable to work my normally scheduled hours, I will contact my volunteer service area coordinator.

Applicant's Agreement (Please read carefully)

I understand and agree that:

Piedmont Athens Regional Hospital has my authorization to thoroughly investigate my work and personal history to include criminal investigations, which also includes submitting to a background check. I will hold no person liable for giving or receiving information in this investigation.

I have applied to work as a Volunteer at Piedmont Athens Regional Hospital and hereby grant permission to release to the hospital any information requested concerning my work ability, character and employment or volunteer service. Prompt response to this request will be appreciated. A copy of my authorization bearing my correct signature has the same force and effect as the original.

I understand that my personal insurance carrier will be the payee if I am injured while carrying out volunteer duties at Piedmont Athens Regional Hospital.

I have read and agree to the above and hereby certify that the facts set fourth in this application are true and complete to the best of my knowledge.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree