Volunteer Application

Must be 18 years or above to complete this online application.  If you are under the age of 18, please contact the Volunteer Coordinator at 765-453-8201 to have a Student Application mailed to you.

General Information
Please include area code.
(or former employer if retired)
Emergency Contact
Work Experience

Work Experience (Please include hospital, medical, or other related experience, if applicable): 

Background

If your answer to any of these questions is "Yes," please provide details below, including, without limitation, the date, description of the charge, conviction or other matter, and place where such action occurred. Please also note that if you are hired by the Hospital, you are obligated to immediately provide information to it in regard to the areas covered by the following questions. Failure to do so may result in immediate dismissal by the Hospital.

Additional Details
Questions
References

Please list 3 work references not related to you whom you have known for at least a year.

Reference 1
Reference 2
Reference 3
Notice

Sanctions Check Notice and Authorization

Howard Regional Health System ("Hospital") Compliance Program is designed to ensure the Hospital's compliance with all federal and state laws and regulations governing its operations. Certain laws governing the Hospital's licensure status and participation in the Medicare, Medicaid and other federal health care programs (such as, 42 U.S.C. 1320a-7, the Civil Money Penalties Act) require the Hospital to ensure the integrity of its employees. The Hospital therefore must conduct a background investigation (hereinafter "Sanctions Check") of all employees (and persons working as a contract employee) in order to determine whether an individual has been excluded from a federal health care program (including the MedicarelMedicaid programs) or sanctioned by a state licensing board. This involves inquiries to national and state medical data banks and law enforcement authorities. This background investigation constitutes a consumer report for employment purpose. The Hospital may obtain the information itself or it may contract with an outside reporting agency (hereinafter "agency") in order to facilitate the collection of the necessary information. The information obtained by the Hospital in connection with the Sanctions Check will be evaluated by the Hospital to ensure its compliance with the federal and state laws governing its operations. THE REPORT WILL NOT BE USED BY THE HOSPITAL FOR ANY OTHER PURPOSE AND WILL REMAIN CONFIDENTIAL. The undersigned authorizes the Hospital to perform the Sanctions Check and to obtain same from an agency if deemed appropriate by the Hospital.

SIGNATURE

*** I have read, I understand and agree to each of the disclosures, authorizations, directions and indemnifications. My typed name below shall have the same force and effect as my written signature.

(mm/dd/yyyy)
Authorization Release

Employment Inquiry Authorization Release

I have applied for employment with Howard Regional Health System ("Howard"). I understand that Howard may obtain a credit and/or consumer report about me, including my criminal history, in order to determine whether I have a satisfactory background and to obtain other information about me in order to assist it in making a decision about my application for employment or in connection with my current employment. I authorize Howard to obtain a consumer report (and I understand that a credit report is a type of "consumer report") for employment purposes, and if employed, at any time during employment for legitimate business purposes, such as in connection with compliance with federal, state, or local laws that may require Howard to obtain such consumer report, or in connection with decisions relating to my retention, promotion, or transfer. I also understand that the above-referenced information may be obtained by Howard from a consumer reporting agency (hereinafter "agency"), and will be evaluated with other information obtained during the screening and interviewing process in connection with any hiring decision, or in connection with the decision to retain, promote, or transfer me if I am hired. The consumer report will not be used for any other purpose.

If, after reviewing the consumer report, Howard intends to make a decision not to hire me (or not to retain, promote, or transfer me), based in whole or in part on information contained in that report, Howard shall: (1) provide notice of such intent to me; and (2) with such notice, provide me with a copy of the report Howard obtained, along with a written description of my rights, as prescribed by the Federal Trade Commission under Section 1681g(c) (3) of the Fair Credit Reporting Act. (hereinafter "Act").

If Howard then decides not to hire me (or not to retain, promote, or transfer me), based in whole or in part on information contained in the consumer report, Howard will: (1) provide notice of such action to me; (2) provide me with the name, address, and telephone number of the agency (including any toll free-number established by the agency) that provided the report to Howard; (3) provide me with a statement that the agency did not make the decision not to hire me (or to retain, promote or transfer me if I am employed), and that the agency is unable to provide me the specific reasons as to why Howard's decision was made; and (4) provide me with notice of my right to request and obtain, pursuant to section 1681j of the Act, a free copy of the report from the agency and to make a request for such report within 60 days of my receipt of notice from Howard informing me of its decision not to hire (retain, promote, or transfer) me, and additional notice that I may dispute with the agency the accuracy or completeness of any information in the consumer report, pursuant to Section 1681i of the Act.

I have read and understand the above, and I understand my rights. I authorize Howard to obtain a consumer report from a consumer reporting agency regarding me. In addition, I release Howard, its agents, and employees from any liability in connection with their use of the report or their reliance thereon in connection with any decision made by them. I understand that the investigative background inquiries that may be made about me may include my criminal, driving, consumer, and other records. These records may also include information as to my character, work habits, performance, and experience along with reasons for termination of past employment. I understand that this report may also include information obtained from various government agencies which maintain records relating to criminal, driving, credit, civil, and other experiences, as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency contacted by Howard any consumer reporting agency used by Howard to furnish the above mentioned information, and release them from any and all liability in connection with such disclosure.

I agree that a telephonic, facsimile, or electronic copy of this release shall be as valid as the original. This release is valid for all federal, state, county and local agencies and authorities.

The following is my complete and legal name, and all information is true and correct to the best of my knowledge.

SIGNATURE

*** I have read, I understand and agree to each of the disclosures, authorizations, directions and indemnifications. My typed name below shall have the same force and effect as my written signature.

(mm/dd/yyyy)
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