Western Baptist Hospital Auxiliary

Western Baptist Hospital Auxiliary

2501 Kentucky Ave. Paducah, KY 42003 contact Greg Holtgrewe 270/575-8450 email -

Adult Membership Application

Date: ______

Name: ______

Address: ______

City: ______State: ______Zip: ______

Cell: ______

Phone: Home: ______Social Sec. No.: ______eMail: ______

In case of emergency, notify:

Name: ______

Phone: ______Relationship: ______

Education background: ______

Work experience: ______

Have you ever been convicted of a felony? Yes: ___ No: ___

Hobbies, skills and interests: ______

______

Previous Volunteer experience: ______

What type of volunteer job are you interested in? ______

______

What is your availability? Days of the week: ______

Hours: ______

What influenced you to be a volunteer at Western Baptist Hospital?

______

List names and numbers of two personal references that are not kin:

Name: ______Phone: ______

Name: ______Phone: ______

I authorize Western Baptist Hospital volunteer Services Department to request information concerning my character and reliability from the above named references.

______

Signature of Applicant

VOLUNTEER

CRIMINAL BACKGROUND RELEASE WAIVER

(Read Carefully)

Have you ever been convicted of a crime (misdemeanor or felony) other than a minor traffic violation? YES NO

If yes, please explain date and nature of conviction(s):

______

Conviction of a crime will not automatically disqualify an individual from approval to become a volunteer. Any offense will be evaluated in relation to the objectives and requirements of the volunteer work area.

I hereby authorize Western Baptist Hospital to obtain records of criminal activity from any source.

Volunteer Name (Please Print)

Volunteer Signature Date Signed

Birth Date:

Social Security #

Street Address:

City, State, Zip: