Faith Community Nursing is a specialized practice of professional nursing that focuses on health promotion and wellness, and is based on the concept of holistic health care--being well in mind, body, and spirit.

Please complete this application if you are interested in becoming a Faith Community Nurse with Ballad Health.

Personal Information

First Name:

Last Name:

Middle Name/Initial:

Preferred First Name (if different):

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Demographic Information

Date of birth:

Criminal Offense: Have you ever:

Policy Restricts Accepting Tobacco User:

Licensure

Please list your current nursing license number, including state and expiration date.

Education

Highest Level of Education:

Please list ALL educational institutions you have attended, including dates and degrees received.

Activities

Please list any community or church activities in which you currently participate.

Emergency Contact

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

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 I must have ACTIVE registered nursing licensure.

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.

I will abide by all ANA requirements for registered nurses.

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 recognition purposes.

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