Please complete this application form if you are interested in becoming a Kingman Regional Medical Center volunteer. Once you complete the form, click the submit button at the bottom.

Name and Address


Personal Information


Relationship

Are you or a family member an employee of KRMC? If so, what department?


Volunteer Interest

Please indicate which areas you are interested in volunteering.


Availability

What days and times are you available to volunteer?


Emergency Contact Information


Volunteer Hours

Why do you need volunteer hours? What school should your hours be reported to?


Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email; however, we will not send you any emails you prefer not to receive. Use the checkboxes below to select the kinds of emails you would like to receive from us.


Electronic Signature

I confirm that the information provided in this application is true in all respects, without any willful omissions. I understand that if this application is false in any way I will be dismissed without notice regardless of when the false information is discovered.

As a volunteer, I
• Agree to complete the volunteer orientation and train until I am competent to perform the required duties.
• Agree to complete an ANNUAL education review and TB screening as well as any additional service-specific training that may be deemed necessary.
• Agree to comply with all of the rules and regulations of Kingman Regional Medical Center.
• Understand that I may be dismissed from my duties for willful wrong doing or negligence and/or performing duties outside of my service guidelines.
• Agree to call the Volunteer Services Manager as soon as possible when I have scheduling changes.
• Agree to accept assignments to a new service area if absent for an extended period of time.

CONFIDENTIALITY: It is the belief of this hospital that all medical, financial, and personal information pertaining to a patient is confidential and is protected from unauthorized viewing, discussion, and disclosure. Therefore, volunteers may look at, use, or disclose patient information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion, or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

I acknowledge and have read the statements above and agree to abide by the expectations of Kingman Regional Medical Center and the Department of Volunteer Services.

By selecting 'I agree', you are signing this application electronically. If you are under 18 years old, a parent or guardian must select 'I agree'.

Parent/Guardian: I hereby give my permission for my son/daughter to join the KRMC Volunteen Program. I will assume full responsibility of his/her transportation to and from KRMC.