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 or Initial:

Preferred First Name (if different):

Address 1:

Address 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Demographic Information

Date of birth:

Criminal Offenses - I have...:

Do you use tobacco/nicotine products?:

Licensure

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

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