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Adult Volunteer Application



Volunteer Services Department

ADULT Volunteer Application

Name:  _______________________________    Date: _______________________________

Address: ______________________________    City: ____________ State: ______________

Date of Birth: __________________________    So Security No: ______________________

In case of emergency, notify: ___________________________ Relationship: _____________

Home Phone:____________________ Work Phone: _______________ Cell Phone: ________

Your current occupation: _______________________________________________________

Have you ever worked for Baptist Health Corbin?  Yes _____     No _____

If yes, when and in what capacity? _______________________________________________

Have you ever been convicted of a felony? Yes _______    No __________

If yes, please explain the offense and date: __________________________________________

Hobbies, Accomplishments, Skills, Interests, Foreign Languages, Sign Language:

____________________________________________________________________________

Previous Volunteer Experience: ___________________________________________________

What type of volunteer work would you prefer? _____________________________________

How often would you like to volunteer? ____________________________________________

On which days are you available to volunteer? _______________  Any evenings: ___________

List names and phone numbers of two personal references (not related): 

Name: ______________________________    Phone: _________________________________

Name: ______________________________    Phone: _________________________________

What influenced you to apply for volunteering at Baptist Health Corbin? __________

_____________________________________________________________________________

I authorize Baptist Health Corbin Volunteer Services Department to request information concerning my character and reliability from the above named references.

_________________________________________    __________________________________

Signature of Applicant                                            Date

 

 

 

REQUEST FOR CONVICTION, RECORDS, MINORS

Pursuant to KRS 17.160 a request is made for any record of conviction of a crime in KRS Chapter 531, 510, 218A and 189A by the person identified herein. This information shall be released to:

________________________________________________________________________________

Agency Name and Address

 

ACKNOWLEGEMENT BY APPLICANT

I have applied for employment as a volunteer in a position involving supervisory or disciplinary power over a minor.  I know that the Kentucky State Police (KSP) will provide the employer with any record I may have for conviction of a crime.  I know that I have the right to inspect my criminal history record and to request correction of any inaccurate information.  If I do not exercise that right, I agree to hold harmless the KSP and any KSP employee from any claim for damages arising from the dissemination of inaccurate information.

APPLICANT INFORMATION (Please Print)

Name: __________________________________________________________________________

          Last                                           First                      Middle                        Maiden

Address: ________________________________________________________________________

              Street                                                 City                      State                  Zip

Sex:  ________    Race: __________    Date of Birth: _____________  So. Sec. #: _____________

______________________________________________    ________________________________

Signature                                                                        Date

______________________________________________    ________________________________

Witness                                                                          Date

 

Instructions:

Employing agencies should ensure that all application information is completed.

Employing agencies should forward a check or money order made payable to the Kentucky State Treasurer in the amount of $10.00 for each submitted form.

The Kentucky State Police will charge a $25.00 fee for each returned check.

Request should be accompanied by two self-addressed stamped envelopes - one bearing the name and address of the requesting agency and the other bearing the name and address of the applicant.

RETURN THIS FORM TO:    Kentucky State Police
                                                Records Branch
                                                1250 Louisville Road
                                                Frankfort, KY 40601