Emergency Contact Information
EDUCATION & TRAINING
ACKNOWLEDGMENT (Please read carefully and sign)
In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete.
I give Adya Hospice & Palliative Care LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, references, and any other persons to answer all questions asked by Adya Hospice & Palliative Care LLC with regard to any of the subjects covered by this application to determine by suitability as a volunteer. I also understand that in connection with my application as a volunteer, Adya Hospice & Palliative Care LLC may conduct a criminal background investigation and that my acceptance as a volunteer may be contingent on the results of such investigation. I release Adya Hospice & Palliative Care LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with applicable laws. I agree that my role as a volunteer may be contingent on the results.