I hereby certify that I have not been convicted and/or found guilty of patient abuse, neglect, or mistreatment, or
misappropriation of patient property in this state or in any state and that I am not listed in any resident or patient
abuse registry in this state or in any other state. I understand that any offer to become a volunteer by Well Care
Hospice is conditional upon verification of this information with the state patient abuse registry and that a listing on
such a registry or registries of any other state may act as an automatic withdrawal of any such offer to become a
I understand that Well Care Hospice requires a thorough background investigation for ALL potential volunteers.
This investigation is limited to only that information required to determine fitness for volunteering and may include
but is not limited to past employment history verification, job performance, disciplinary record, financial/credit
history, and a criminal background investigation. By affixing my signature to this document, I agree to hold harmless
any previous employer, agent of that corporation, or any individual or organization providing information pursuant
to this Authorization.