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SCMC Auxiliary
Please provide two personal references (Please exclude relatives)
1.)Name ____________________________
Phone ____________________________
2.)Name ____________________________
Phone ____________________________
Emergency contact ________________________
Phone_________________________
Relation to Applicant ____________________________
Have you ever been employed by Stone County Medical Center or White River Health System? yes no
The information I have provided is accurate to the best of my knowledge. Your signature indicates your approval for us to check references. The organization is not obligated to provide volunteer placement, nor are you obligated to accept the volunteer position offered.
Applicant Signature ________________________
Date _________________
Annual Membership Dues: Active status- $5.00 / Inactive status- $10.00
*All SCMC/WRHS Volunteers are bound by Patient Confidentiality/Privacy Laws and must sign a Confidentiality Statement. All Volunteers must attend a WRHS orientation (first Monday of the month) at White River Medical Center in Batesville - 10:30am-4:30pm.
Please fax completed form to:
Tena Bledsoe, WRHS Auxiliary Director
at (870) 262-1458 or for more information you may e-mail tbledsoe@wrmc.com
To arrange for an interview or follow up on the status of your application, please call Mary Branch at 870-269-9225.
Thank you for your interest in the SCMC/WRHS Volunteer Team!! Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.
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