Banner Desert Medical Center & Cardon Children's Medical Center BANNER DESERT and CARDON CHILDREN'S MEDICAL CENTERS TEEN VOLUNTEER APPLICATION

BANNER DESERT and CARDON CHILDREN'S MEDICAL CENTERS TEEN VOLUNTEER APPLICATION

If you are 16 to 17 years of age, please complete this volunteer application for Banner Desert or Cardon Children's Medical Centers. Once you complete the form, click the submit button at the bottom of the application.

WE HAVE TWO TEEN PROGRAMS, our REGULAR ONGOING TEEN PROGRAM and our SUMMER TEEN VOLUNEER PROGRAM.

OUR REGULAR ONGOING TEEN VOLUNTEER PROGRAM, is ongoing and does not have an end date. You are expected to commit to a minimum six month assignment, and Volunteers are expected to serve a minimum of one 4 our shift per week.

------------------------------------------------------------------------------------------------------------------------

IF YOU ARE SIGNING UP FOR OUR SUMMER TEEN VOLUNTEER PROGRAM; in the "VOLUNTEER SCHEDULE AND TIME AVAILABIITY" section, please confirm that you applying to be a SUMMER TEEN Volunteer and are available to volunteer one 8 hour shift per week from May 28, 2019 though July 31, 2019.

APPLICANTS STATEMENT OF UNDERSTANDING

I understand applicants are invited to participate solely at the discretion of staff, and this application does not guarantee a call back, invitation to interview, or an offer of volunteer position.

Legal First Name:

Legal Last Name:

Legal Middle Name:

Title:

Nickname:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Primary Phone phone:

* OK to call me here

Secondary Phone phone:

OK to call me here

Cell phone:

Email address:

SCHEDULE COMMITMENTS AND REQUIREMENTS

We are currently recruiting for individuals who can commit to a minimum of 6 months to 1 year of volunteer service, or more, serving one regular 3-4 hour scheduled shift per week. If you are unable to meet the time requirement. Please complete this application at a later date

* Pre-screening confirmations:

I agree to serve my time commitment

I can volunteer one 3-4 hr. shift a wk.

I have previous volunteer experience

I will agree to a Background Check

I will obtain an Annual Flu Shot

* English Language Proficiency:

Read fluently

Speak fluently

Write

DEMOGRAPHIC INFORMATION

Please complete the following:

PARENTAL OR GUARDIAN CONSENT

Teens ages 16-17 must have a parent or guardians consent to volunteer. Please enter your Parent or Guardians information process, as you will need their approval to move forward in the application, per-boarding, and onboarding process.

1

2

First name:

Last name:

Nickname:

Street 1:

City:

State:

Zip:

Primary Phone phone:

Secondary Phone phone:

Email address:

VOLUNTEER SCHEDULE AND TIME AVAILABILITY

TEEN VOLUNTEERS WILL NOT BE PLACED IN DIRECT PATEINT CARE ASSIGNMENTS

If you are interviewed and offered a volunteer position, your availability to serve as a volunteer is very important. What is your availability and schedule preference?

PHYSICAL and MEDICAL BACKGROUND INFORMATION

Do you have any physical limitations or medical condition, that may limit your ability to perform the duties. If "YES", please explain:

* Medical limitations select one:

YES

FELONY QUESTION

Have you, under this name or any other name, ever been convicted of a felony or a felony that was reduced for sentencing purposes including DWI/DUI (excluding any minor traffic violations)? If YES, state the offense, disposition:

* Felony question select one:

YES

VERIFICATION OF IDENTITY

I agree to provide my date of birth and Social Security number to verify I have not been excluded from participation in any Medicare, Medicaid or other federal health care procurement program.

OIG EXCLUSION

Banner requires all Screening Subjects to immediately disclose if they are currently excluded, debarred, suspended, or otherwise ineligible to participate in Federal Health Care Programs or in federal procurement or non-procurement programs. All Screening Subjects must also immediately disclose if they have been convicted of a criminal offense that falls within the scope of 42 U.S.C. § 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible.

AGE REQUIREMENT

By submitting this application, I certify that at the time of this application, I meet the minimum Teen Applicant Age Requirement of 16 years of age.

COMMITMENT TO CONFIDENTIALITY and ONBOARDING

By Checking "I Agree" and submitting my application, I am stating that, to the best of my knowledge, the information I have provided is true and correct. I agree to:

1. Hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, visitors, physicians, nurses, and all Healthcare Staff.

2. I will not seek confidential information regarding any patient.

3. Uphold the Core Values, Performance Standards, and People Experience expectations of the Banner Health System.

4. Endeavor to serve with compassion, empathy, accountability, responsibility, and excellence.

I understand that my services are donated to the Banner Healthcare System without contemplation of compensation or future employment, and given for humanitarian or charitable reasons. I verify the preceding information on this application is true. I understand that there are many types of volunteer opportunities within the Banner Healthcare System and as a pre-boarding and onboarding, I will be required to complete all Pre-boarding Requirements, including; New Volunteer Orientation (NVO)and, or Department/Unit Training, a Background Check and Occupational Health Screening.

I also understand that for whatever reason, at their sole discretion, Banner Health Volunteer Services reserves the right to withdraw an offer to volunteer and to close my volunteer application.

I Agree