Belton Regional Medical Center Volunteer Application 17065 S. 71 Highway Belton, Missouri 64012 Volunteer Services (816) 348-1201 Required fields are marked with an asterisk *. Contact InformationToday's Date *E-Mail Address *Name *Spouse NameAddress *City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip *Phone *Date of Birth *License Plate #StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDriver's License #Emergency ContactEmergency Contact *RelationshipAddress *Phone Number *Education and ExperienceHigh School Attended *Year Graduated *CollegeDegreeYear GraduatedPrevious Work ExperiencePrevious Volunteer ExperienceReferences(IMPORTANT: List at least 3 references from a business, school, clergy or other volunteer experience. Do not use physicians or relatives.) 1.Name *Business/Org *Phone *Address *Relationship *2.Name *Business/Org *Phone *Address *Relationship *3.Name *Business/Org *PhoneAddress *Relationship *Availability and ConfirmationDay(s) Available * Mon. Tue. Wed. Thur. Fri. Sat. Sun.Time availableWould you be interested in other volunteer service at the hospital? Yes NoHave you ever been convicted of a crime other than a parking ticket? * Yes NoIf yes, DatePlaceType of ConvictionType of Sentence ReceivedConviction will not necessarily disqualify individuals from volunteer servicesI affirm that the information provided on this application is true and complete. I understand that before I begin my volunteer service, I will be interviewed, consent to a reference check (Background History Record Information), attend orientation, and provide proof of TB skin testing or I will receive necessary required testing prior to beginning my volunteer service. I understand that this application does not guarantee a volunteer placement at Belton Regional Medical Center and that if accepted, I will not receive payment for my service.Signature *Date * Rate Your Experience Submit SuccessThe form was successfully sent. There was an error with the form submission.