Norton Community Hospital
100 Fifteenth Street NW
Norton, Virginia 24273
(276) 679-9774

Please enter your information below to submit your Application for Membership to the Volunteers of Norton Community Hospital.

(* = Required Items)

First Name*:

Middle Name:

Last Name*:

Phone*:
(e.g... XXX-XXX-XXXX)

Date of Birth*:

   

In Case of Emergency Contact*:

Relationship*:

Emergency Contact Phone*:
(e.g... XXX-XXX-XXXX)

Physician’s Name*:

Office Phone*:
(e.g... XXX-XXX-XXXX)

Hours Available for Work*:

Interests, Talents, Hobbies*:

Would you be interested in serving on a committee?*

List 2 References other than Family:

Name 1*:

Phone 1*:
(e.g... XXX-XXX-XXXX)

Name 2*:

Phone 2*:
(e.g... XXX-XXX-XXXX)

 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.

BY SUBMITTING THIS YOU ARE SIGNING IT WITH YOUR NAME AS YOU ENTERED IT.

   

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

.