Please complete this application form if you are interested in becoming a Volunteer Chaplain at Ballad Health. Once you complete the form, click the submit button at the bottom.

Contact Information

First Name:

Last Name:

Middle Name/Initial:

Preferred First Name (if different):

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Emergency Contact Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Contact's Employer:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Educational Information

Highest Level of Education:

Major/Degree:

Ordainment and License

Please indicate if you are ordained and/or licensed and include dates for each:

Church Information

Please tell us the name of your current Church, the address, and your position/title at your Church:

Demographic Information

Date of birth:

Gender:

Policy Restricts Accepting Tobacco User:

Social Security Number:

Active Military / Veteran?:

Other Information

Availability

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

Statement of Call

Please tell us your goal and reason for becoming a Volunteer Chaplain:

Volunteer Chaplain Agreement

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