You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

What skills do you have that could help impact the patient experience?

What Critical Needs Area are you interested in giving service? What other areas are you interested in giving service?

Please fill in your availability below.

Please include contact information for at least 2 (up to 3) individuals that would be a reference for you.

Please enter your preferred emergency contact below.

What are you hoping to gain from this volunteer experience?* (Required)

Please carefully read each of the attestations below before clicking “Attestations' Agreement” below. Note that minors (under 18) will have paper signature pages that need parent/guardian signatures before starting.

 Volunteer Confidentiality Agreement/Attestation

The purpose of this Agreement is to document the understanding of Carle’s privacy and confidentiality expectations. In an effort to ensure the privacy and confidentiality of all Carle information in any form, including patient records, business operations, and other proprietary data that the Volunteer may encounter during Volunteer assignments, the Volunteer agrees that: 1. All patient information shall be treated with the utmost privacy and confidentiality, 2. Any patient information of which they become aware during the course of their encounters with Carle shall not be disclosed or discussed with anyone, 3. They will not request any patient specific information from Carle as part of the encounter with Carle, 4. Any patient information the Volunteer encounters is incidental to the purpose of their presence at Carle, 5. Any and all Carle business information the Volunteer receives or encounters during the course of conducting business with Carle is Carle’s confidential business information, 6. They will not disclose or discuss any Carle business information with any third-party unless specifically authorized by Carle to do so, 7. They will promptly report any observed HIPAA incidents to the Carle Compliance Department in accordance with Carle’s policies and procedures, 8. Any breach or violation of this Agreement by the Volunteer shall be cause for immediate termination of the relationship between them and Carle. I also understand that the Carle Foundation reserves the right to add, change, and/or update any related policies and procedures as may be required from time to time. I furthermore attest that I will complete HIPAA and privacy training as part of my volunteer orientation and will follow the guidelines set forth during this training.

Safety, Professional Conduct and Security Agreement/Attestation

I agree to abide by the following standards and the related Carle policies and procedures designed to comply with the laws and regulations to protect the safety of patients, myself, fellow Volunteers and Carle staff. I understand that the failure to follow any of the provisions listed below may result in my immediate removal from the Volunteer activity I am participating in at Carle as well as civil and/or criminal penalties. The following is prohibited: 1. Falsifying any Carle record or document or willfully providing false information to Carle, or a government agency, customer, insurer, or similar entity. 2. Unauthorized access to, possession, use, copying, or reading of Carle records, or the disclosure of information contained in such records to unauthorized persons. 3. Theft of unauthorized use of Carle property or the property of others while on Carle premises. 4. Deliberate or negligent destruction of Carle property or the property of others while on Carle premises. 5. Accepting personal gifts, money, or services in return for special consideration in any Carle business or service activity, or otherwise violating the Carle’s Conflict of Interest Policy. 6. Unauthorized possession or use of intoxicants or other behavior affecting substances on Carle premises. Being under the influence of intoxicants while on Carle premises. 7. Sexual solicitation or harassment on Carle premises or while representing the organization. 8. Unauthorized possession or use of any weapon on Carle premises or while representing the organization. 9. Fighting or similar behavior that is disturbing, threatening, or injurious to patients, employees, or others on Carle premises. 10. Conviction of a felony, or violation of any local, state or federal statute with which Carle must comply. 11. Negligence and/or disregard of safety regulations or common safe practices. 12. Failure to report conduct by anyone that a reasonable person should know is criminal that occurs on Carle premises or while conducting Carle business. 13. Other - This list is not exhaustive and should not be construed to limit the Carle’s right to include other types of conduct within this category. I understand that the failure to follow any of the provisions listed below may result in a verbal or written reprimand. I further understand that the second instance of reprimand for any one of these items may lead to my immediate termination from the program with which I am participating. 1. Poor performance—based on Carle Behavior Standards. 2. Inattention to duty such as excessively engaging in behavior that is not related to volunteering. Examples include personal internet use, game playing or excessive use of instant messenger, texting, emailing or making personal phone calls or other activities of a personal nature. 3. Leaving assigned area during duty time without permission of staff or other person in authority. 4. Failure to notify staff or assigned designee when unable to report for volunteering as scheduled. 5. Excessive absenteeism, tardiness or sleeping while on duty.  6. Insubordination—refusal to carry out the specific directions or instructions of staff or other person in authority 7. Unauthorized use of Carle telephones for personal needs. 8. Failure to comply with traffic and automobile parking regulations on Carle premises. 9. Other - This list is not exhaustive and should not be construed to limit the Carle’s right to include other types of conduct within this category.  I understand that Carle reserves the right to revise, add, change and update the documents I received and related policies and procedures as may be required from time to time.  I furthermore attest that I will complete training about safety, professional conduct and security as part of my volunteer orientation and will follow the guidelines set forth during this training.

Volunteer Agreement and Release/Attestation

Carle Health and Carle Health Volunteer Services (collectively “Carle”) and I (Volunteer) agree that in exchange for the opportunity to volunteer with Carle, the following terms shall apply: 1. The Volunteer will perform services under the direction and control of Carle staff. 2. The Volunteer agrees to follow the directions of the staff and to abide by Carle policies and procedures while carrying out these volunteer services. The Volunteer acknowledges that Carle follows the requirements of federal, state and local legislation regarding equal employment opportunity when signing this Agreement. 3. The Volunteer is not an employee of Carle and is not entitled to receive salary, benefits, or other compensation. 4. To the extent Volunteer is not a citizen or permanent resident of the United States, Volunteer certifies that he/she has an appropriate visa status that authorized the Volunteer to be present in the United States and allows Volunteer to participate in the experience. 5. The parties agree that this is the entire Agreement, and no agreement, oral or written, exists outside of this Agreement. 7. The Volunteer understands and agrees that the information contained in this Agreement does not constitute an employment contract or volunteer contract between Carle and the Volunteer, and that either the Volunteer or Carle may terminate the volunteer relationship at any time with or without cause.

Volunteer Waiver and Release of Liability/Attestation

Carle facilitates a volunteer program to enhance the healthcare experience for those we serve (“Program”). As used herein, “Carle” means The Carle Foundation and its affiliates and subsidiaries, including, without limitation Carle Foundation Hospital, Carle Oral Auditory School, Arrow, Carle Physician Group, Champaign Surgery Center, Carle Hoopeston Regional Health Center or Carle Richland Memorial Hospital, Carle BroMenn Medical Center, Carle Eureka Hospital, and its departments, trustees, officials, employees, agents, officers, directors, and representatives. I, the Undersigned acknowledge that in consideration for participation in any way in the Program, hereby agree to the following:

Risks of Activity. Undersigned acknowledges that Undersigned has: (i) sole responsibility to evaluate the risks in participating in the Program, (ii) have fully considered the risks, and (iii) voluntarily assumes and accept full responsibility for any and all risks and dangers of participation in the Program, whether or not described, known or unknown, inherent or otherwise. Undersigned further acknowledges that in taking advantage of the Program, Undersigned voluntarily chooses to participate in the Program.

Release of Liability. Undersigned unconditionally releases, forever discharges, and agrees not to sue Carle from/for all claims, liability and rights of action, including litigation costs, expenses and reasonable attorneys’ fees for any claims, expenses, loss, damages, liabilities or causes of action for any liability or loss of any nature, including personal injury, death, and property damage, arising out of or relating to the Undersigned’s participation in the Program, including, but not limited to claims of negligence, willful misconduct, any allegation the Program is not appropriate or suitable for Undersigned, any matter related in any way to participation in the Program, any lost or stolen property, breach of warranty, and/or breach of contract, and any other claim whether or not described above, known or unknown, inherent or otherwise, that Undersigned may or will have against the Carle.

Insurance. Further I understand that Carle does not assume any responsibility for or obligation to provide Undersigned with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. Undersigned expressly waives any such claim for compensation or liability on the part of Carle beyond what may be offered freely by Carle in the event of injury or medical expenses incurred by Undersigned.

Medical Treatment. Undersigned hereby releases and forever discharges Carle from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during Undersigned’s tenure as a volunteer with Carle

Miscellaneous. In the event that any provision or aspect of this agreement be found to be unenforceable, that all remaining provisions of the agreement will remain in full force and effect. This agreement shall be governed by the laws of the State of Illinois and the exclusive jurisdiction and venue for any claim shall be located in the state courts located in Champaign County, IL. This agreement shall be binding upon the subrogors, distributors, heirs, next of kin, spouse, executors, and personal or legal representatives of the Undersigned and Undersigned.

Signature

By checking “Attestation Acknowledgement” below, it constitutes the same as my signature and agreement to abide to the attestations above, including:

• Volunteer Confidentiality Agreement/Attestation
• Safety, Professional Conduct and Security Agreement/Attestation
• Volunteer Agreement and Release/Attestation
• Volunteer Waiver and Release of Liability/Attestation

I further attest my understanding that following these guidelines is a condition of my continued participation in the Volunteer Services program.  I, the Undersigned, acknowledge that I have read these attestations carefully and fully understand their contents. I hereby certify that I am at least 18 years of age and am legally competent to sign this release form. I acknowledge that, but for signing this document, I would not be permitted to participate in the Program.

Checking this box below shall have the same force and effect as my written signature.

Have you ever received notification that you cannot work or volunteer for a healthcare organization that participates in federal or state healthcare programs such as Medicare or Medicaid? Type Yes or No below.