Please complete this application form if you are interested in becoming a University of South Alabama Mitchell Cancer Institute Chemo Sabe adult volunteer. Once you complete the form, click the Continue button at the bottom of the page.


Contact Information

Please list your full legal name. If you go by a nickname or a name other than your first name, please list it in the nickname or preferred name section.



Why are you interested in volunteering?


Demographic Information

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



Email Preferences

We like to keep volunteers informed of required "checklist reminders" such as annual flu shots or Tb skin tests. Please do not remove Checklist Reminders from your field. We also like to include important news, schedules, and upcoming events by email. We will not, however, send you any email you prefer not to receive. Use the checkboxes below to remove any kinds of email you would NOT like to receive from us.



Employer Experience

Please list your current or most recent employer. If you have not been employed, please skip to the next question.



Volunteer Experience

Please list your most recent volunteer experience(s).



Relatives Employed at USA

If you have any relatives who are employed through the University of South Alabama, please list their name and the department in which they work.



Community Affiliations

Please provide contact information for one current or previous community group or employer that you are (have been) affiliated with that may be contacted as a reference. List additional community groups you are active with in the box below.



Emergency Contact

In the event of an emergency whom should we notify?



Criminal History

Have you ever been convicted of a felony or misdemeanor (including pleading guilty or nolo contendere)? Falsifying this or any other information on the application is grounds for immediate dismissal. By completing this application you are acknowledging that you are aware that volunteer applicants may be subject to a background screening check. We will discuss this with you prior to initiating.



Availability

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



ACKNOWLEDGEMENT & CONFIDENTIALITY PLEDGE

ACKNOWLEDGEMENTS & CONFIDENTIALITY PLEDGE


The information I provided for this application is accurate and correct to the best of my knowledge. I approve USA MCI to check references. USA MCI is not obligated to provide a volunteer placement, nor am I obligated to accept the placement offered. Opportunities for volunteering are provided without regard to religion, creed, race, national origin, age or gender.


I recognize the necessity of maintaining the confidentiality of all data and documents collected and processed by USA MCI. Confidential information is defined as proprietary business data or information which contains identifying information which can be linked to a specific individual or patient. I also recognize the importance of my part in assuring the right to privacy of persons and institutions cooperating with this facility. I further understand that this facility has both ethical and legal responsibilities to safeguard confidential information. Therefore, I will not divulge any confidential information I may encounter while volunteering at USA MCI. Further, I will not make any copies of or transport off the premises any confidential information. I am aware, that in some instances, civil and criminal penalties are possible if unauthorized disclosure of confidential research records and data occurs. I agree to accept any liability which may accrue to this facility for any breaches of confidentiality which occur through my direct action.


I HEREBY AGREE THAT I WILL ABIDE BY THE POLICIES OF USA MCI. I UNDERSTAND THAT IF I VIOLATE ANY OF THESE POLICIES, I MAY BE DISMISSED FROM THE VOLUNTEER PROGRAM. I HAVE CONSIDERED THE SERIOUSNESS OF THE COMMITMENT I AM MAKING AS A VOLUNTEER.


BACKGROUND & HEALTH SCREENING REQUIREMENTS


I understand that if USA MCI decides to make an offer to volunteer that such offer is conditioned on my satisfactory completion of any necessary background and health screening requirements, including receiving annual flu vaccination. I also understand that, prior to my being accepted as a volunteer, USA MCI may request a third party background investigation to determine my suitability for volunteering. If such a background investigation is requested I will be notified in writing prior to initiation.


RELEASE FROM LIABILITY


I understand that I will be voluntarily participating in the Volunteer Program at USA MCI. In consideration of the University of South Alabama permitting me to participate in this activity, I, in full recognition and appreciation of any and all risks, hazards, or dangers, if any, inherent in this activity, to which I may be exposed, do hereby agree to assume all of the risks and responsibilities surrounding participation in such activity.


I do for myself, my heirs and personal representatives, hereby defend, hold harmless and indemnify, release and forever discharge the University of South Alabama, its trustees, officers, agents, servants and employees from and against any and all claims, demands and actions or causes of action on account of or resulting from my participation in this activity and/or which may result from causes beyond the control of, and without the fault or negligence of the University of South Alabama, its trustees, officers, agents, servants and employees, during the period of participation as aforesaid.


I fully understand the risks involved in this activity and agree to assume those risks. I understand that the University of South Alabama, its trustees, officers, agents, servants and employees assume and accept no liability for wages of any kind, personal injury or loss of life or damage to personal property.