Please complete this application form if you are interested in becoming an SSM Health volunteer. Once you complete the form, click the submit button at the bottom. Please note that fields marked with an asterisk (*) are required.


Site Selection

Please indicate how you first learned about volunteering with us and which SSM Health site(s) you are interested in. Please select all that apply.



SSM Health Questionnaire

To help us better know you and further assess your qualifications for this position, please answer the following questions as accurately as possible. Please note that the tobacco question only applies to positions in Missouri.



Personal Information and Volunteer Experience

Please enter all relevant personal information in the fields below. If you need an email address, please contact your local volunteer office. (+) Denotes information required to conduct a background check on all applicants.


Please note the following definitions of Volunteer Type:

-Adult Volunteer: An adult not enrolled in school

-College Student Volunteer: Currently enrolled in higher education

-Offsite/Restricted Volunteer: Will not serve on-site in SSM Health facilities and will not have patient contact

-Youth Volunteer: Currently enrolled in high school or below



Time, Talent, and Interest Inventory

Please indicate your GENERAL availability to volunteer below. Check all that apply. Actual volunteer schedules will vary depending on individual assignments and will be determined in consultation with staff. (Please note that service areas vary by site.)



References

Please list two personal or professional references. (Please do not include relatives.)



Current Employment

If you are currently employed, please provide the name of your employer, the title of your position, your start date and whether it is a full-time or part-time job.




Emergency Contact

Should you become a volunteer with us, who may we contact in the case of an emergency? Please list name, relationship and contact information. If you are under 18, please provide information for your parent or guardian, including their email address.



Criminal Record

Have you ever been convicted of or pled guilty or nolo contendere to a misdemeanor or felony (other than minor traffic offenses)?


You should answer "no" if the record of conviction has been sealed, expunged, impounded, pardoned, or annulled by a court of law or statute. In Missouri, you should answer "no" if you received a suspended imposition of sentence where probation has been successfully completed and the case terminated. In Illinois, Wisconsin, and Oklahoma, you must disclose convictions with deferred sentences.

A "yes" response to the preceding question may not disqualify you from consideration for volunteering. Consideration will be given to the nature and gravity of the offense(s), the time that has passed since the offense(s) occurred, and the nature of the job sought. Please provide a complete response to the question.



Civil Complaints/Investigations

Have you ever had civil complaints or civil investigations against you regarding child, elder or patient abuse?



Health Care Related Offenses

Have you ever had civil or administrative actions taken against you by any governmental agency of private party for health care related offenses?


A "yes" response to either of the preceding questions may not disqualify you from consideration for volunteering. Please provide a complete response to the questions.



Education

Please list the highest education achieved below.



Diversity Information

Please provide the information requested in the fields below regarding diversity.


SSM Health is committed to building and maintaining a diverse and high quality workforce and providing equal opportunity for all persons. To help us evaluate SSM Health's commitment, please consider providing the requested information regarding diversity. The information is kept confidential and is only used in accordance with applicable laws and regulations, including those that require the information to be summarized and reported to the Federal Government for civil rights enforcement. When reported, data will not identity any specific individual. Thank you.



Volunteer Application Statement

Please read the following statement carefully, then acknowledge that you have read and approved it by checking the "I Agree" checkbox at the bottom of the page, which constitutes your esignature. Please note that an esignature is the electronic equivalent of a hand-written signature.


I certify that all information in this application is true, accurate and complete. I understand that any misrepresentation or omission of fact in this application may result in denial of volunteer opportunity. I understand and agree that submitting this application form does not automatically register me as a volunteer. I understand that I will be performing services as a volunteer without compensation. I understand and authorize SSM Health, directly or through an outside vendor, to obtain an investigative consumer report and request information from public and private sources, consistent with the duties of the volunteer position, about my driving record, criminal record, education, former employment, credentials, and credit. I understand that under the Fair Credit Reporting Act (FCRA), I am entitled to know if volunteering is denied based on information obtained from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source providing the information. By indicating my agreement with this statement, I authorize to release any and all information concerning any background checks and reference checks to SSM Health or its agent. SSM Health does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other legally protected status under local, state, and federal law.


DO NOT E-SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT.


By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement.


Please signify your acceptance by checking the "I Agree" checkbox below and then click on "Continue".


After you successfully submit your application, a confirmation will be sent to the email address you have provided.