About Us Volunteer Volunteer Application

Volunteer Application

Memorial Hospital Auxiliary Online Volunteer Application

Memorial Hospital is an Equal Opportunity Employer. Memorial Hospital is a non-smoking facility. Smoking is prohibited within the hospital and on the hospital campus. You must be 18 years of age to apply.

"*" indicates required fields

1Your Information

2Reference Information

3Volunteer Agreement

Please designate which Hospital location you prefer to volunteer.*

Personal Data

Name*

First Middle Last

Date of Birth*

Month

Day

Year

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Secondary Phone

Do you speak any foreign languages?*

Yes

If yes, please list the foreign languages you speak:

Have you ever been convicted of a crime?*

Note: Convictions include guilty plea and please of nolo contendere. A conviction will not necessarily bar you from volunteer status. Each conviction will be judged on its own merits as to time, circumstances, and seriousness.

Yes

Please explain:*

Emergency Information

Emergency Contact Name*

First Last

Relationship to You*

Home Phone Number*

Mobile Phone Number

Volunteer Experience

Please list any previous volunteer experience.

Questionnaire

Why are you interested in volunteering?*

Is there anything that may adversely affect your ability to perform volunteer duties?*

Yes

Please explain.*

Would you be interested in serving on the Auxiliary Board of Directors?*

Yes

Please select all areas that you are interested in working in the hospital.*

Gift Shop

Cancer Resource Center

Escorts

Flower Delivery

Surgery Waiting Room

Same Day Admit

Vendor Sales

Cardiac Cath Lab Waiting Room

Infusion Clinic (CHF) Waiting Room

Emergency Department

Pet Therapy (requires certification)

ICU Waiting Room

How did you hear about the Memorial Auxiliary?*

When can you start volunteering?*

Other

Please share any information you think would help us get to know you. This can be work history, hobbies, etc.

References

Please list two personal references other than family.

Reference #1: Name*

First Last

Reference #1: Contact Number*

Reference #1: Relationship to You*

Reference #2: Name*

First Last

Reference #2: Contact Number*

Reference #2: Relationship to You*

Today's Date*

Month

Day

Year

Signature*

I certify that this application is correct to the best of my knowledge and understand that references will be checked.

If accepted as a hospital Volunteer, I agree that:

I shall hold absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, or personnel, and not seek to obtain confidential information from a patient.
My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian, religious, or charitable reasons.
I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, both on or off hospital property or act as a runner or capper for an attorney in the solicitation of business. I shall report all known occurrences of solicitation for attorneys to the Manager of Community and Corporate Relations.
I shall not sell or attempt to sell goods or services, request contributions, or to solicit persons to sign or distribute political petitions on hospital premises unless I receive the express authorization of the Manager of Community and Corporate Relations to engage in these activities.
I shall be punctual and conscientious; conduct myself with dignity, courtesy, and consideration of others and endeavor to make my work professional in quality.
I shall attempt to resolve any problems related to my Volunteer activities with the Manager of Community and Corporate Relations.
I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept.
I shall, at all times, uphold the philosophy of the hospital.
I understand that the Manager of Community and Corporate Relations reserves the right to terminate my Volunteer status as a result of (a) failure to comply with hospital policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances, which in the judgement of the department manager, would make my continued service as a Volunteer contrary to the best interests of the hospital.

Signature*

I have read the above conditions and agree to be bound by them.

MS SAFER

Mississippi Screening Assurance for Employee Enrollment and Registries

Name*

First Middle Last

SSN*

Date of Birth*

Month

Day

Year

Race*

Gender*

Height*

Weight*

Hair Color*

Eye Color*

Are you a U.S. Citizen?*

Yes

Place of Birth*

Have you lived in any state (other then your current state) in the last two years?*

Yes

List previous state(s) lived in during the last 2 years.*

Please list location and dates you lived there. Example: Mobile, AL May 2021 to August 2022

Have you ever used other names/aliases?*

Yes

Please list other names/aliases you have used.

Example: John Doe, Joe Smith

MSDH Noncriminal Justice Applicant's Privacy Rights

Mississippi State Department of Health

Noncriminal Justice Applicant’s Privacy Rights

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As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for a job or license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.

You must be provided written notification¹ that your fingerprints will be used to check the criminal history records of the FBI.
If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.
The officials must advise you that the procedures for obtaining a change, correction, or updating of your criminal history record are set forth at Title 28, Code of Federal Regulations (CCFR), Section 16.34.
If you have a criminal history record, you should be afforded a resonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal history record.²

You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.³

The Mississippi State Department of Health will provide you with a copy of your Mississippi and FBI criminal history record for review and possible challenge. Should you lose or misplace the provided record, you may obtain a copy from MSDH by submitting a request for the duplicate record which includes appropriate identifying information and a $15 fee.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the state agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the state agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.34.)

Your signature on the fingerprint card and/or this document indicates that you have been informed of your privacy rights and understand that your fingerprints are being run through the criminal history records of the FBI.

1. Written notification includes electronic notification but excludes oral notification.
2. See 28 CFR 50.12(b).
3. See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 42 U.S.C. 14616, Article IV (c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

Date

MM slash DD slash YYYY

Signature

Fingerprint Request Form

Date

MM slash DD slash YYYY

This is to request fingerprinting on an:*

Applicant

Employee

Volunteer

Name

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Month

Day

Year

SSN*

Phone

Manager's Name

First Last

Agency Privacy Requirements for Noncriminal Justice Applicants

Authorized governmental and non-governmental agencies/officials that conduct a national fingerprint-based criminal history record check on an applicant for noncriminal justice purposes (such as job or license, immigration or naturalization matter, security clearance, or adoption) are obligated to ensure the applicant is provided certain notice or other information and that the results of the check are handled in a manner that protects the applicant’s privacy.

Officials must provide to the applicant written notice¹ that his/her fingerprints will be used to check the criminal history records of the FBI.
Officials using the FBI criminal history record (if one exists) to make the determination of the applicant’s suitablility for the job, license, or other benefit must provide the applicant the opportunity to complete or challenge the accuracy of the information in the record.
Officials must advise the applicant the procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.
Officials should not deny the job, license, or other benefit based on information in the criminal history record until the applicant has been afforded reasonable time to correct or complete the record or has declined to do so.
Officials must use the criminal history record solely for the purpose requested and cannot disseminate the record outside the receiving department, related agency, or other authorized entity.²

The FBI has no objection to officials providing a copy of the applicant’s FBI criminal history record to the applicant for review and possible challenge when the record was obtained based on positive fingerprint identification. If agency policy permits, the courtesy will save the applicant time and additional FBI fee to obtain his/her record directly from the FBI by following the procedures found in 28DFR 16.30 through 16.34. It will also allow the officials to make a more timely determination of the applicant’s suitability.

Each agency should establish and document the process/procedures it utilizes for how/when it gives the applicant notice, what constitutes “a reasonable time” for the applicant to correct or complete the record, and any applicant appeal process that is afforded the applicant. Such documentation will assist State and/or FBI auditors during periodic compliance reviews or use criminal history record for noncriminal justice purposes.

Signature*

Date*

MM slash DD slash YYYY

Employee Health Services

HealthCheck

HealthCheck Form 2000

Name*

First Last

Date of Birth*

Month

Day

Year

Sex*

Job/Department*

Physical History

Have you suffered any serious health problems in the past year?*

Yes

If yes, describe them:*

Are there any persons living in the same household as you or with whom you have frequent contact that have a communicable disease?*

Yes

If yes, please explain:*

When is the last time you saw a doctor or health care provider?*

Why?*

Please select any disease you have had in the past:*

Measles

Mumps

Chicken Pox

Whooping Cough

Diptheria

Polio

Scarlet Fever

Pneumonia

Brucellosis

Malaria

Typhoid

TB – Tuberculosis

Salmonella

Shigella

Hepatitis

Rubella

Have you had any broken bones/injuries?*

Yes

If yes, please describe:*

What accidents have you had:

At home?

Please list any accidents you may have had at home.

In jobs?

Please list any accidents you may have had on the job.

While driving?

Please list any accidents you may have had while driving.

Have you ever had any trouble with a strained back?*

Yes

If yes, please explain:*

Were you ever compensated for on-the-job injury or disease?*

Yes

If yes, describe the disability, cause, duration:*

Are you now drawing disability benefits from the Government or an insurance company?*

Yes

If yes, explain:*

Do you take medicine regularly?*

Yes

If yes, please list them:*

If more than one, please separate with a comma.

List know allergies (drugs, vaccines, food, etc.)*

Date of last Tuberculin test:*

Month

Day

Year

Result:*

Date of previous immunizations:

Tetanus Toxoid

Polio

Measles

DPT

Diptheria/Tetanus

Mumps

Influenza

Hepatitis B

List of operations and approximate dates:*

Do you have any physical problem that will prevent you from fully performing the duties of the job for which you have been selected or for which accomodation must be made?*

Yes

If yes, describe:*

Describe the state of your health:*

Name of family doctor/primary care provider:*

Signature

Date

Month

Day

Year

(228) 867-4077

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