Please complete this form if you are interested in helping at the Center on an episodic or occasional basis. This can be a one time only opportunity for an individual or a group of volunteers. If you are interested in volunteering more than one time per month, you must complete full registration with the Volunteer Department. Although all requests will be considered, we may not be able to fulfill all requests. Thank you.


Name and address


Information about you or your group


Availability

Please indicate the days and times you are usually available to volunteer.



Other

Is there any additional information we need to know to inquiry that may help us best serve you or your group?



Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.



Important Safety Information for Volunteers

All volunteers, and groups of volunteers, must review a copy of the "Important information for volunteers" flyer that is provided by the Center. Review of this flyer is mandatory and must be completed prior to your volunteering at the Center. DuPage Convalescent Center will provide this information to you in advance of your volunteer service. Group leaders are responsible for ensuring others have access to the information in advance.



Additional Information and Confidentiality

****Please note: All volunteers will be required to review and sign this information and statement in person. Volunteers under 18 years of age will also require parental permission.


DuPage Care Center is an equal opportunity employer and adheres to the principles and practices outlined in applicable federal, state and local laws and regulations that prohibit discrimination in employment and hiring. It is the policy and practice of the County to recruit, select, hire, train, promote, demote, terminate, compensate and administer all employment practices without regard to race, color, ancestry, national origin, religion, age, sex, sexual orientation, marital status, veteran status, medical condition,pregnancy, or physical or mental disabilities unrelated to the ability to perform essential job functions with or without reasonable accommodations (except where a bona fide occupational qualification exists). Furthermore, the County is committed to complying with the Americans With Disabilities Act. If an applicant requests a reasonable accommodation for purposes of completing the job application process, the County reserves the right to require professional documentation to confirm the need for accommodation.


If accepted as a Volunteer at the DuPage Care Center:


I understand that under the Health Insurance Portability and Accountability Act (HIPAA) guidelines, resident protected health information (PHI) is required by law to maintain the privacy of medical information pertaining to our residents. PHI includes: Any individually identifiable health information that is transmitted or maintained by DPCC; Identifies an individual or offers a reasonable basis for identification; relates to a past, present or future physical or mental health condition; is created or received by DPCC.


I shall hold confidential all information that I may obtain directly or indirectly concerning residents, doctors or personnel, and not seek to obtain confidential information from a patient. Discussing information about a resident with employees (other than directly involved with that resident’s care) with other residents, volunteers, visitors, friends, neighbors or otherwise unauthorized individuals is inappropriate.


I understand that Ia m not an employee of DuPage County, or any of its offices or departments for any purpose. My services are donated to the facility without contemplation of compensation or future employment, and given with humanitarian, religious or charitable reasons.


In consideration of the opportunity and benefit afforded to me by participating with the above described volunteer activity and/or program, I hereby agree to hold harmless, release and forever discharge the County of DuPage, and all their officers, agents, servants and employees from any and all claims or causes of action of any kind including but not limited to personal injury, death, loss of or damage to property, or any other action which arises or may arise from my involvement in the volunteer activity and/or program described above and any of the operations conducted incident thereto, or any other volunteer activity I may engage in with the County of DuPage that may not be described above.


I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies “for compensation” both on or off of DuPage Care Center property, or act as a runner or capper for an attorney in the solicitation of business. I shall report all known occurrences of solicitation for attorneys to the Supervisor of Volunteer Services.


I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on Care Center property, unless I receive the express authorization by the Supervisor of Volunteer Services to engage in these activities.


I shall submit to background checks and examinations, which may include chest x-rays, skin tests, appropriate laboratory tests and/or immunizations that may be necessary as part of my volunteer service. I authorize the person(s) making tests or x-ray films to report the results to the Care Center. **TB testing is required of all volunteers and is free of charge.


I shall attempt to resolve any problems related to my volunteer activities with my supervisor, and, if unsuccessful, attempt to resolve any such problems with the Volunteer Services Supervisor.


I shall make my best effort to fulfill my commitment to the Care Center by completing all assignments that I accept and uphold the mission and standards of the DuPage Care Center.


I understand that photos are often taken at facility events and activities. Such photos may be used to post in house or for marketing initiatives for the Center. By signing this agreement, I authorize use of my photos for this purpose.


I understand that the Volunteer Services Department reserves the right to terminate any volunteer status as a result of (a) failure to comply with DuPage Care Center policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgment of the department Supervisor, would make my continued services as a volunteer contrary to the best interests of the DuPage Care Center.


I also certify that the statements made in this volunteer application are true and correct, and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release the DuPage Care Center from any liability whatsoever for supplying such information.


By checking the agree box, it acts as my signature; I acknowledge that all the information contained herein is true and accurate to the best of my knowledge.