Volunteering Form

Mississippi County Hospital System

Volunteer Profile

Please complete the following. Answer all questions.

Name *

Last, First, Middle Initial

Address *

Mailing Address

Home Phone *

Cell Phone *

Email Address *

Work Phone:

Present Employer: *

Business Experience: *

Volunteer Experience: *

How were your referred to volunteer services at Mississippi County Hospital System? *

Volunteer Service Areas Available *

(check more than one if interested)

Gift Shoppe Volunteer Contacting ER Patients Assisting our visitors Office/Clerical Clergy

I would like to volunteer on the following days: *

During the following times: *

Morning Afternoon Evening

In case of emergency, please notify *

Name and Number

REFERENCES: (Please list two people who are not relatives)

Reference 1: *

Name Phone Years Known

Reference 2: *

Name Phone Years Known

I understand that volunteering services in hospital settings Is not without risk or exposure to disease, including, but not limited to, Human Immunodefiency Virus (AIDS), Hepatitis B, and other communicable infectious diseases. However, with training, which will be provided as part of the orientation program and strict adherence by the volunteer to the training, exposure to and risk of contracting the disease can be reduced. Understanding this, the undersigned expressly assumes the risks of participating in the volunteer program and releases and discharges Mississippi County Hospital System and employees , from any and all liabilities or claims arising from or related to the exposure to or contraction of any disease(s), ailment(s), or condition(s) as a result of participating in the volunteer program at Mississippi County Hospital System.

Volunteer Signature: *

Date *