Please complete this application form if you are interested in becoming a volunteer at The Valley Hospital. Selecting 'I Agree' below shall have the same force as your written signature. Once you complete the form, click the submit button at the bottom.

Please enter all information in UPPER CASE.

* Required fields.


Contact Information


Emergency Contact

In the event of an emergency whom should we notify?



Education


References

Please include two professional/personal references, excluding relatives.

You must provide an email address for each reference.

Applicants without complete reference information will not be considered or contacted.

If one of your references is a Valley Hospital employee/volunteer, enter 'Valley Hospital' under Street.



Assignment Preference

The following volunteer assignments may currently be available. Please select your preferences.



Health Insurance

If I am accepted as a Valley Health System Volunteer, I understand that I must maintain my own health insurance. Valley Health System does not provide health insurance for Volunteers even if services are sought due to illness or injury while providing volunteer services.

Please enter today's date and acknowledge agreement with above.



Confidentiality Statement

VALLEY HEALTH SYSTEM, INC. Ridgewood, N.J.

VOLUNTEER STATEMENT OF CONFIDENTIALITY


In connection with my relationship with Valley Health System, The Valley Hospital, Valley Home Care, or Valley Medical Group, as applicable (collectively, Valley Health System), I acknowledge and agree that I have a legal and ethical responsibility to safeguard the privacy of all confidential information of Valley Health System which I may receive, come into contact with, or use and disclose, including but not limited to patient clinical and financial information, business, operational and related confidential information of Valley Health System and its patients, employees, contractors and other affiliated individuals and entities.

I acknowledge and agree that I must maintain such information in the strictest confidence throughout the course of my relationship with Valley Health System and thereafter, in accordance with all applicable Health Insurance Portability and Accountability Act (HIPAA) and related Valley Health System policies. I acknowledge and agree that I may only access and use Valley Health System patient and other information where I have a need to know to provide care or perform my job responsibilities, and that I will further disseminate such information to only those other individuals who have a need to know, only as permitted by Valley Health System policies. When patient information must be discussed with any health care practitioners, patients or other individuals during the course of my work, I will use discretion to assure that such conversations cannot be overheard by others who are not involved in the patient's care or who would otherwise not be authorized to have access to such information.

I acknowledge and agree that I am prohibited from accessing patient information for patients I am not working with and cannot access patient information related to family members, friends, colleagues or other individuals, regardless of whether they may give me permission to access such. If I am issued a username and password for access to Valley Health System computer systems, whether on-site or remote, I understand and agree that such credentials are for my use only and that I am responsible for all access and entries performed using such username and password. I agree to safeguard the confidentiality of such password, and will not post, share or otherwise distribute my password. I agree to contact the Information Systems Department immediately if I have reason to believe the confidentiality of my password or username has been compromised.

I acknowledge and agree that, in the event my relationship with Valley Health System has terminated, I will immediately discontinue any access to, use or disclosure of Valley Health System patient and other information. I will immediately return or present for inspection any badges, unique tokens, laptops or mobile devices which are the property of Valley Health System or which may contain Valley Health System information. I further acknowledge and agree that I may not keep copies of patient information after my relationship with Valley Health System has terminated, whether such copies may be paper or electronic, and will immediately return any such copies to Valley Health System.

By clicking on ‘I Agree’ below, I acknowledge that I have read the above and accept the responsibility associated with these statements. I understand that violation of this agreement may be cause for disciplinary action or immediate termination of my relationship with Valley Health System.



Authorization

By clicking submit, I acknowledge that I have read, understand and agree to comply with the Valley Health System Volunteer Statement of Confidentiality. I consent to Valley Health System's use of the information I have provided for the purpose of evaluating my Volunteer Application. I understand that providing false or misleading information may be cause for immediate termination of my association with Valley Health System or any volunteer assignment. I understand that use of the internet to transfer information may not be secure and is subject to the Valley Health System Website Privacy Policy.



How To Contact Us

Volunteer Resources Dept.: 201-447-8135