(Note: Criminal offense convictions will not necessarily disqualify an applicant - All facts and circumstances will be considered)

I hereby certify that all the information contained on this application is true and complete. I authorize Ballad Health to contact all sources necessary to verify this information and to check references as deemed necessary. I understand that any misstatement of omission on this application is cause for loss of volunteer privileges.

I hereby understand and consent that my photograph may be taken for the purpose of promotion of services at Ballad Health Hospice, which is deemed appropriate. I am aware I will not receive payment of any kind for my participation and grant Ballad Health Hospice the rights to use regardless of my future association with the organization and for an unrestricted time.

I acknowledge and accept my role as a volunteer with Ballad Health Hospice. I understand my fundamental duty is to provide professional and compassionate care to patients and their families. I will maintain appropriate and professional boundaries with patients, caregivers, families, and other Hospice team members at all times.

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 and possibly civil and/or criminal prosecution.

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 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.

If accepted, I acknowledge that in my role as a volunteer with Ballad Health Hospice my fundamental duty is to provide professional and compassionate care to patients and their families. I will maintain appropriate and professional boundaries with patients, caregivers, and other Hospice team members at all times. My role when working with clients of Mountain States Hospice is that of a friend and supportive person. When long term or intensive phsycotherapy is needed, I will confer witht he professional consultant about appropriate referral. I will attend training sessions and follow-up Volunteer meetings as scheduled throughout each year. If at any time I am unable to carry out a responsibility for Ballad Health Hospice, I will give prior notice if at all possible. I understand that record keeping is an important part of the agency. I WILL KEEP ALL RECORDS ABOUT CLIENTS UP-TO-DATE.

I understand and agree that submitting this form does not automatically register me as a volunteer and that there may be other qualifications I must meet, including the acceptance of established volunteer policies and procedures and completion of training(s) before I may begin volunteering.

AGAIN, I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER:

"I will abide by Ballad Health's policies concerning patient confidentiality."

"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 promotional reasons."

"I will observe all hospital regulations."

CHECKING THE "I AGREE" BOX AND SUBMITTING THIS FORM WILL SERVE AS YOUR ELECTRONIC SIGNATURE AND YOUR ACCEPTANCE OF THE AGREEMENT ABOVE.