Volunteer Advisory Team

Catawba Valley Medical Center values the opinions and expertise of our community members, and often includes community members on committees and councils. If you are interested, or have been invited to join a group, please fill out the form below.

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Volunteer Advisory Team Member Application

Name *

Address *

Phone *

Email *

Please tell us what interests you about becoming part of our Advisory Team? *

Have you ever been convicted of, pleaded guilty or no contest, or paid a fine for any criminal offense? (Not including minor traffic violations) *

YesNo

If yes, please explain *

Please list 3 references (not spouse, partner, or related to you) that we may contact

First Person

Name *

Phone # *

How long have you known this person? *

Relationship *

Second Person

Name *

Phone # *

How long have you known this person? *

Relationship *

Third Person

Name *

Phone # *

How long have you known this person? *

Relationship *

If selected as an Advisory Team member I agree to have a criminal background check and attend training and informational sessions before attending any CVMC meetings. I agree to keep any patient related information confidential and I understand if I do not

Signature *

Date *

Verification

Please enter any two digitsExample: 12
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