Peer Help Volunteer Application
Please complete this application if you are interested in becoming a Peer Help Volunteer with Ballad Health.
Personal Information
First Name:
*
Last Name:
*
Middle Name or Initial:
Preferred First Name (if different):
Address 1:
*
Address 2:
City:
*
State:
Choose
AK
AL
AR
AZ
CA
CANADA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
Home phone:
*
Cell phone:
*
Email address:
*
Demographic Information
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
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31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
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1967
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
*
Criminal Offenses - I have...:
Choose
been convicted of a crime
not been convicted of a crime
*
Education
Please list ALL educational institutions you have attended, including dates and degrees received.
Activities
Please list any activities or other volunteer opportunities in which you currently participate.
Emergency Contact
First Name:
Last Name:
Home phone:
Work phone:
Cell phone:
Relationship:
Choose
Aunt
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Sibling
Son
Spouse
Supervisor
Uncle
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 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
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