I hereby affirm that the information provided on this application is true and complete to the best of my knowledge, and agree to have any of the statements verified by St. Mary’s. I understand that providing any false or misleading information or any omissions may disqualify me from further consideration as a volunteer and may result in my immediate termination even if discovered at a later date. I authorize all references provided in this application, as well as all other individuals to provide all information they have about me. Furthermore, I agree to cooperate in such investigation and release from liability or responsibility, the Medical Center and all persons and entities acting on its behalf, and all persons and entities requesting or supplying such information.
Please enter date in this format: mm/dd/yyyy
Read and complete Part A and Part B. Part A requires a signature should an emergency arise while on duty. Part B requires authorization for a PPD test.
It is legally required to obtain consent prior to treating a volunteer in the Emergency room should an illness or injury occur while he/she is on volunteer duty. Please sign below to give permission to give any necessary first aid or emergency treatment should an illness or injury occur while you are on duty.
I give the Employee Health Department of St. Mary’s Medical Center authorization to give a PPD test (Tuberculin skin test) and required immunizations.
