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McCullough-Hyde Memorial Hospital

Pre-Volunteer Background Inquiry Release

McCullough-Hyde Memorial Hospital

Pre-Volunteer Background Inquiry Release

Electronic Signature:**

Date:**

Parent / Guardian Signature (If volunteer is less than 18 years of age):

Date:

Please sign the Declaration above and fill out the form below and submit with your volunteer application.

The following information is required to conduct the background investigation.

Last Name:**

First Name:**

Middle Initial:

Previous or maiden name (if applicable):

Street Address:**

City:**

State:**

Zip Code:**

Phone Number:

Email Address:**

Driver's License Number:**

State Issued:**

List states and counties of residence, other than above, for the past seven (7) years:

For identification purposes only (optional)

Date of Birth:

Sex:

Security Clearance

A conviction record will not necessarily be a bar to volunteering. Factors such as job relatedness, age at the time of offense, type of offense and rehabilitation will be taken into account.

Have you ever been convicted of a misdemeanor or felony?**YesNo

Have you ever served time, been on probation or currently on deferred offense?**YesNo

I certify that the information above is correct.

Electronic Signature:**

Date:*

Parent/Guardian signature (If volunteer is less than 18 years of age):

Date: