Auxiliary Member Application

Member Application
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Winter Address (if different than primary address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:
example@example.com
Preferred Method of Communication:*

EmailPhone CallText Message
I am interested in the following volunteer positions:*

Gift Shop: Monday-Friday (9am - 12:30pm & 12:30pm - 4pm)Cafeteria: Monday - Friday (11am - 1:30pm)Pharmacy: Flexible (once per month)Therapy Services: Monday - Friday ( 9am - 12pm)Office Support: Times VaryAnnual Fundraising Support: Times VarySurgery/Orthopaedic Escort Monday & Wednesday (8:45am - 10:30am), Tuesday (8am - 11am)
Emergency Contact:*

NamePhone NumberRelation
Have you received your COVID Vaccination?

YesNo
Have you received your annual flu shot?

YesNo

Tuberculosis (TB) is on the rise and healthcare has strict guidelines in monitoring this disease. Have you had any of the following?

	Yes	No
Fatigue
Night Sweats
Fever
Traveled to a Foreign Country
Positive or Questionable Mantoux
Exposure to TB
Cough for more than 3 weeks
Bloody Sputum
Weight Loss or No Appetite
Unresolving Respiratory Illness
Chest X-ray or Prophylaxis for TB

Authorization for Release of Information for Criminal Background Check
Previous Names/Maiden Name/Former Name/Also Known As:
Social Security #:
Dates of Residence at current address:
From:Enter Date to Current
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of Residence:
From: Enter Date To: Enter Date
Please list prior Counties and State in which you have lived if the two listed above do not encompass the last 7 years:
MN Driver's License # DL #
or Current Driver's License # from another stateDL #
I authorize the release of any and all information to Verificed Credentials, Inc. in their background investigation of my criminal history. Verificed Credentials, Inc. is authorized to release to Riverwood Healthcare Center and its agents any personal information about me relative to the conviction, guilty plea, or nolo contender plea for any crime.

I further understand and waive my right of privacy in this investigation and release and hold harmless Riverood Healthcare Center and its agents from any liablity in this investigation.

I agree that if any misrepresentation has been made by me herein, or the results of such investigation are not satisfactory, any offer of employment made may be withdrawn, or my employment terminated immediately.

THIS AUTHORIZATION EXPIRES ONE YEAR FROM THIS DATE.
I would like a copy of my report:

YesNo
Applicant Signature:*

Clear
Relationship if signing for minor:
Date:*

MonthDayYear
Date
Should be Empty: