Volunteer Application


Have you ever worked or volunteered for this organization before?*


Education / Special Training: *


Work Experience:*


How did you hear about our volunteer program?

In which area you would like to volunteer?*

Indicate which days you wish to volunteer:*


Criminal History Disclosure

Missouri Law HB 1362 requires an applicant to provide the following information:

Do you have any criminal history to discolse (as defined below)?

"Criminal History" includes any conviction or a plea of guilty to a misdemeanor or felony charge and shall include any suspended imposition of sentence; any suspended execution of sentence or any period of probation or parole.

Please list charges in the following format:


Criminal History Records Disclosure Consent

As a requirement of the Volunteer application process, by typing my name below, I consent to release of my criminal history record to Nevada Regional Medical Center. Nevada Regional Medical Center will consider material contained in my criminal history records solely for the purpose of determining my suitability to volunteer. I understand that a prior conviction may not necessarily disqualify me for volunteering, but will be a factor which may be considered in the decision. I do not authorize release of this information for any other purpose beyond this decision.