Please complete this application if you are interested in becoming a Peer Help Volunteer with Ballad Health.


Personal Information


Demographic Information


Education


Activities


Emergency Contact


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.