Thank you for your interest in volunteering at Colquitt Regional Medical Center. We appreciate the people from our community who are willing to join with us to make a difference by volunteering. You aren’t just volunteering with this decision, you are joining an elite membership of a Volunteer Auxiliary. The greatest rewards come from the heart and you can make a difference in someone’s life by starting with these simple steps:
ü Complete and return your application, along with a $15 application fee made payable to Volunteer Auxiliary and return to Volunteer Services.
ü Volunteer services will contact you to schedule an interview.
ü Complete Colquitt Regional Medical Center’s drug screening, criminal background check and tuberculosis test with our Employee Health nurse.
ü Bring your smiling face to Human Resources and have a volunteer name badge made.
ü Complete Colquitt Regional Medical Center’s employee orientation.
As a volunteer, your benefits would include:
· One uniform top
· You receive a free meal in the cafeteria on your volunteer workday.
· Ladies receive a free baseline mammogram and baseline dexa screening each year
· Men receive a free PSA screening
· Active volunteers may purchase prescriptions at the hospital pharmacy at employee cost.
· An invitation to the annual awards banquet and honored with a gift at this event
· A 40% discount in the Pink Pearl gift shop
· The opportunities to travel to attend Volunteer Auxiliary conferences
We look forward to receiving your completed application. Should you have any questions, please feel free to contact Lexi Radcliff at 229.891.3416 or by email at
Application for Membership
Name:______Date: ______
Spouse’s name: ______Home Telephone:______
Cell Phone: ______Email address: ______
Home Address: ______City: ______
In case of emergency, notify (name & telephone number)______
Church affiliation: ______Family physician: ______
Birth date: ______Date of last medical exam: ______
How did you hear about our volunteer program and why does volunteer work interest you?______
_
What do you hope to gain from your volunteer service? ______
Do you have special skills or training in your background? Please list.
Do you have any special mental or physical limitations that should be considered in your placement (wheelchair accessibility, assistive listening devices, etc.)?
Have you ever worked at Colquitt Regional? ______
Polo Size:______Jacket size: ______
Preferred type of work: (circle one) office work, errands & patient transport, public relations (lots of interaction with visitors, patients, etc.)
Preferred departments:
Preferred workdays:______Preferred hours:______
Please provide three (3) personal letters of references (non-family members please).
*Please include a $15 application fee.
Colquitt Regional Medical Center
Human Resources
3131 South Main Street
PO Box 40
Moultrie, Georgia 31776
(229)890-3533
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify thatI have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by MBI Worldwide, Corporate Headquarters, 101 North Park Drive, Suite 200, Herrin, IL 62948, (866) 275-4624, www.mbiworldwide.com, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be asvalid as the original.
New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □
BACKGROUND INFORMATION
Please print/type the requested information. Lack of legible or missing information may delay processing of this request.
Applicant Name: ______
Last First Middle
Other names known by (Including Maiden)______
Present Address: ______
Street City State Zip County
Date of Birth: ______/______/______Driver’s License # ______State ______
(MM/DD/YYYY)
SS#: ______Male / Female (Circle One) Race ______
Home Addresses for the Past 7 Years: (List additional addresses on separate page, if needed.)
Street Address City State/Zip County Dates Mo/Year
______
Phone Number: We may need to contact you for additional information or to clarify information on this form.
(Area Code) + Telephone Number
This information will be used for background screening purposes only and will not be used as hiring criteria.
Signature: Date:
THIS IS TO CERTIFY that I agree to abide by the rules and regulations of the Volunteer Auxiliary of Colquitt Regional Medical Center and the department to which I may be assigned. I expect no monetary compensation for these services.
Signed______