Application for Membership
Dickenson Community Hospital Auxiliary, Inc.

312 Hospital Drive
P.O. Box 1440
Clintwood, Virginia 24228
(276) 926-0300

Name_________________________________________________________________________________
First                                       Middle                                        Last

Address_______________________________________________________________________________

Telephone (H) ___________________ Date of Birth _____________________

In Case of Emergency Contact: __________________________________Phone____________________
                  Name/Relationship

Physician’s Name ______________________________ Office Phone _____________________________

Hours Available for Work ________________________________________________________________

Interests, Talents, Hobbies_______________________________________________________________

_____________________________________________________________________________________

List 2 References: Name_________________________________ Phone:__________________________
(other than family)
                           Name_________________________________ Phone:________________________

Would you be interested in serving on a committee? ___Yes ___No

I hereby make application for membership in the Dickenson Community Hospital Auxiliary. I agree to
uphold the purpose, policies and procedures of the auxiliary and the institution that it serves.

I understand that if I am accepted as a Volunteer:

¨        I will abide by the hospital’s general policy concerning patient confidentiality.

¨        My assignment is on a probationary basis for a period of 60 days.

¨        I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a result of my services and the facility is not legally liable for any worker’s compensation coverage or other similar benefit as a result of my services.

¨        Photos taken while participating as a Volunteer or at special functions may be used for promotional reasons.

¨        I will observe all hospital regulations.

My membership is contingent upon payment of annual dues, annual orientation, PPD, and criminal background history.

__________________________________________                _______________
            Signature                                                         Date
 

We are a member of VAHAV, the Virginia Association of Healthcare Auxiliaries and Volunteers.