Auxiliary Application

Thank you for your interest in the Beauregard Health System Auxiliary! Please complete the information below to submit your application.

*First name:

*Last name:

Physical Address:

City:

State:

Zip Code:

*Mailing Address:

*City:

*State:

*Zip Code:

*Home phone number:

Cell phone number:

*Date of birth:

*Family doctor:

*Emergency contact:

*Emergency contact's phone number:

*Relationship of contact to you:

*1st Reference (not a relative):

*Reference's contact number:

Reference's address:

*2nd Reference:

*Reference's contact number:

Reference's address:

*Were you referred by someone?

If yes, please list their name:

*Are you acquainted with an active or previous Auxiliary member?

If so, please list their name(s):

*Were you previously employed?:

If yes, where?:

Please give a brief description of your duties:

*Times you are able to work:

Morning Afternoon

*Days you are able to work:

Monday Tuesday Wednesday Thursday Friday

*Please give a brief statement as to why you would like to be an Auxiliary member:

*Auxiliary work stations and duties are listed below. If you have a preference, please indicate by making a check in the appropriate box.

Surgery Waiting: Serve coffee and give assistance when needed to the families of patients who are in surgery. Hours are from 7:00 am until surgeries are complete. Patient Information Desk: Give assistance to visitors; give patient room numbers as requested; answer the telephone to give information. Same Day Surgery: Give assistance to visitors and register patients for outpatient exams and procedures. Emergency Department: Greet patients, help patients get registered, and give help to visitors as per registration clerks. Gift Shop: Conducts sales and keeps shop tidy.

There are other miscellaneous duties that the hospital staff may request. Your chairperson will supervise these.

*I understand that it is required that an active member must work 50 hours minimum in the hospital each year.

All applications must be approved by the Auxiliary Board of Directors. The Board reserves the right to approve or reject any application with or without cause.

*I consent to a background investigation, including drug testing. All information obtained will remain confidential and will be used by the BHS Auxiliary, solely for the purpose of application as a volunteer. I have read the above statement and submit my application.

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