Please complete this application form if you are interested in becoming a Volunteer for Johnston Memorial Hospital. Once you complete the form, click the submit button at the bottom. If you provide an email address, you will receive an email with further instructions on the next step. If you do not have an email address, a Volunteer leader will contact by phone.

Contact Information

First Name:

Last Name:

Middle Name or Initial:

Preferred First Name (if different):

Address 1:

Address 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

Email address:

Have you volunteered before with Ballad:

Yes

Demographics and Personal

Date of birth:

Do you use tobacco/nicotine products?:

Social Security Number:

Emergency Contact

First Name:

Last Name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Availability

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

Preferences in Volunteering

Are you required to volunteer?:

Yes

Briefly explain why you are interested in volunteering; or if you are required to volunteer, by whom?

Skills and Experience

Please tell us more about the skills and experience that you have. Check all that apply:

Please list any previous volunteer experience:

Criminal History

Have you ever been convicted of, or pled guilty to a criminal offense (misdemeanor or felony)? (We do criminal background checks. Falsification of this or any other information on the application is grounds for immediate termination from the Volunteer program. A conviction does not necessarily disqualify you from volunteering.)

Criminal Offenses - I have...:

If Yes, please explain:

Anything Else?

Please provide us with any additional information that you feel will help us know more about you.

I Agree

I understand and agree that at no time will any information regarding patients of Ballad Health be revealed to anyone other than those authorized to receive it. I understand that the giving of the information concerning a patient to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.

I agree to any necessary health screening required by the hospital and understand my volunteer assignment is contingent upon successful completion of this screening.

I UNDERSTAND I MUST HAVE A TB SKIN TEST (and Flu shot during Flu season) BEFORE I CAN BEGIN VOLUNTEERING. The hospital will perform the TB skin test and Flu shot at no charge to the volunteer.

I understand that false statements made as a part of this enrollment may be considered sufficient cause for dismissal.

I authorize and consent for all named references and educational institutions or previous places of employment to release any personal and/or professional information about me to the Volunteer Office. I also consent to a law enforcement record search and/or any other background investigation of me if chosen by the Volunteer Office. I understand I have consented to these things as described herein, and in doing so, I further release, hold harmless, and indemnify Ballad Health, the Volunteer Office, and any and all Ballad Health employees, officers, directors, and/or authorized agents, as well as those individuals or entities supplying such information about me, and/or conducting such search and/or investigation, from any liability, claims and/or causes of action as a result of any such inquiry, search and/or investigation.

I understand and agree that submitting this form does not automatically register me as a Ballad Health volunteer and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER:

"I will abide by Ballad Health's policies concerning patient confidentiality."

"My assignment is on a probationary basis for a period of 60 days."

"I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a result of my services, and Ballad Health is not legally liable for any worker s compensation coverage or other similar benefits as a result of my services hereunder."

"Photos taken while participating as a Ballad Health volunteer or at special functions may be used for promotional reasons."

"I will observe all hospital regulations."

Checking the "I Agree" box and submitting this form is your electronic signature and your acceptance of the Agreement above.

I Agree