I certify that the statements made in this volunteer application are true and correct. I understand that this information may be disclosed to any party with legal and proper interest and I release St. Alexius Medical Center from any liability whatsoever for supplying such information. I understand that I will not be paid for my services as this is strictly volunteer work. I authorize representatives of St. Alexius Medical Center to contact any of my schools, former employers or other references to provide applicable information relevant to the volunteer position for which I am applying. Representatives of St. Alexius Medical Center, in separate documentation, will ask to obtain a criminal background report. I understand that this consent if valid for the duration of my volunteer assignment. I release St. Alexius Medical Center as well as any schools, employers, law enforcement authorities or other references from any liability as a result of the verification process. I understand that if I falsified any information or omitted any material facts, termination of volunteer assignment may result at any time. I agree to abide by requirements set by the Volunteer Services Department, which includes annual medical screening and annual safety training.

I Agree    I Disagree