Volunteer Application Name* Date* MM slash DD slash YYYY Race Gender Female Male Address* Address City State Zip Home Phone Cell Phone Email Social Security Number Volunteer Opportunity Type*Hospital VolunteerHospice VolunteerVolunteer ChaplainJunior / Teen VolunteerSelect the Volunteer Opportunity you are seekingEducationHigh School Name Graduate/Year College Name Previous ExperienceList most recent first.Employer (company name)Job Duties Have you ever been employed by Cullman Regional Medical Center?* Yes No Are you related to anyone who works with Cullman Regional Medical Center?* Yes No Have you been convicted of a felony in the last 5 years?* Yes No Describe your ConvictionPlease briefly describe the circumstances of your conviction, including date, nature and place of the offense and disposition of the case. Your answer is looked upon as only one of the factors considered in the decision and is evaluated in terms of the nature, severity and date of the offense. Do not include arrests without convictions, convictions adjudged youthful offender, or convictions for drunkenness, simple assault, speeding, minor traffic violations or disturbance of the peace. Conviction of a crime will not necessarily disqualify you. Each conviction will be judged on its own merits with respect to time and job relatedness.Release AuthorizationIn connection with my application as a volunteer with Cullman Regional Medical Center, I confirm that the information on this form and contained in my application is true and complete. I understand that any false or misleading representations or omissions made on my application or during my volunteer tenure could disqualify me from providing further volunteer services and may result in the termination of my volunteer status. I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including, without limitation, criminal records, personal history and others. These reports will include experience along with reasons for termination of past employment. Further, I understand that you will be requesting information from various Federal, State, local and other agencies which contain my past activities. I hereby authorize without reservation, any party or agency contacted by Cullman Regional Medical Center, 1912 Alabama Highway 157, Cullman, Alabama, 35058, its management, employees, independent contractors and/or other third party agents of Cullman Regional Medical Center, to furnish the above referenced information to Cullman Regional Medical Center the above referenced information to Cullman Regional Medical Center and/or its affiliated and to answer all questions and release all information concerning my employment record, character, reputation, ability, education, military service, credit history and other applicable information. Furthermore, I release all agencies, bureaus, employers, information service organizations, and individuals or companies named in my application or otherwise identified by Cullman Regional Medical Center and/or its representatives, contractor, or agents form all liabilities and damages that might result from information provided in good faith. I further release Cullman Regional Medical Center and its employees, independent contractors, affiliates and/or third party contractors from all liabilities and damages related to the request for, and evaluation and use of, the information and/or reports obtained as contemplated hereby I further authorize ongoing procurement of the above mentioned reports and information at any time during my volunteer tenure. I have the right to make a request of CIC Applicant Background Checks, 1-866-859-0143, upon my provision of proper identification and the payment of any authorized fees, for the information in its files on me at the time of my request. I understand that the information requested below, including, with limitation, date of birth, race and gender, is solely for the purpose of gathering information accurately and will not be used to discriminate against me in violation of the law. Have you read, understand and authorize Cullman Regional Medical Center (not sure what this statement should be)?* Yes In a few words please tell us why you would like to volunteer at CRMC and if you have a preference as to a department you would like to volunteer in.Signature My typed name below shall have the same force and effect as my written signature.