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