Patient Family-Centered Care Application

Are you a St. Jude patient or are you related to a St. Jude patient?

Unfortunately, if "no" is chosen above, you will not be eligible to volunteer.

_{We recommend you apply to the St. Jude community volunteer program instead}_{by clicking here}_.

Relationship to patient

If other relationship, describe

Personal Information

* First Name

Middle Name

* Last Name

First Name (preferred)

Country

Home Address Line 1

Address Line 2

Address Line 3

* Address

Apartment or Steet #

* City

* State/Province

* Zip (US)/Postal (CA)

Does your permanent address differ from the address you entered earlier in the application?

* Permanent address

* Apartment or Street #

* City

* State/Province

* Zip (US)/Postal (CA)

Country

* Phone (Cell)

Phone (Home)

Phone (Alternate)

* Email address

* Date of Birth

Gender

Race

Race expanded

* Ethnicity

Ethnicity-Additional

Have you been convicted of a felony?

* If yes, please explain. A conviction does not necessarily omit you from volunteering. We may follow up with you for more information.

Will you need an accommodation or modifications in order to volunteer? Examples: ASL interpreter, Text-to-Speech, Large-Print Documents

* Please explain the type of accommodation your need.

 Our institution collects and reports the below data to send to regulatory agencies. Have you received a COVID-19 vaccine? *Please note that currently, you do not have to have the vaccine to volunteer.  

Do you have access to the following technology?
Select all that apply

Cellphone

Smartphone

Landline phone

Reliable Internet Access

A tablet or smart device

A webcam or a device with a camera

Would you be interested in learning more about stipends and our technology loan options?

* Please describe the type of support you are interested in

How did you hear about the Patient Family-Centered Care Program

* Other

Which of the following areas interest you?

_{Check all that apply}

Assist in education

Assist other families

Participate in surveys

Serve on committees

Work on staff initiatives

Other (please specify below)

* Interest Area/Other

Please list any other languages besides English that you speak fluently

Has a friend or family member currently or previously worked or volunteered with the hospital?

Please list their full name(s):

Have you been or are you currently employed by St. Jude Children's Research Hospital, ALSAC, or Children's GMP, LLC.

Please select all that apply:

* Department

* Supervisor

Patient Information

* Patient First Name

Middle Name

* Last Name

Patient Preferred Name

* MRN

* Patient Date of birth

* Age of patient at diagnosis

Gender

Race

Additional Race Information

Ethnicity

Additional Ethnicity Information

Primary Clinic (Select one or more):

A Clinic: Leukemia

ACT Clinic: After Completion Therapy

B Clinic: Bone Marrow Transplant

D Clinic: Solid Tumor

E Clinic: Neurology

H Clinic: Hematology

ID Clinic: Infectious Disease

Other (Please specify below)

RO Clinic: Radiation Oncology

* Primary Clinic/Other

* Diagnosis

Treatment Status

When is the treatment expected to be completed?

What is the date of their passing?

Indicate all clinics and departments the patient has had experience with (Select one or more):

Bone Marrow Transplant

Child Life

Clinical Nutrition

Diagnostic Imaging

Endocrinology

ICU

IMCU

Infectious disease Clinic

Inpatient

Medicine Room

Other Areas (please specify below)

Palliative Care

Physical Therapy

Psychology

Radiation Oncology

Rehab

School Program

Social Work

Spiritual Care Services

Surgery

* If other clinics:

Did the patient receive care at a St. Jude affiliate?

If yes, which affiliates?

Baton Rouge LA

Charlotte NC

Huntsville AL

Johnson City TN

Peoria IL

Shreveport LA

Springfield MO

Tulsa OK

Did you live in any St. Jude housing?

Select all the housing you lived in:

Domino's Village

Ronald McDonald House

Target House

The Parcels at Crosstown

Tri Delta Place

Other (please specify below)

* Housing/Other

Care Team Member Name

Is there anything else about you, your child, or you experiences at St. Jude that would be helpful for us to know? (Examples: Prosthesis, additional surgeries or support received, other relevant diagnoses, unique experiences, other areas of expertise)

Availability

Are you aware of any reason that would prevent you from volunteering on a consistent basis for 1 year?

Please explain:

Do you have any question, concerns, or comments to share?

Agreements

Confidentiality Agreement

I understand and agree that in the performance of my duties as a volunteer of St. Jude Children's Research Hospital, I must hold patient information in confidence. Hospital volunteers have an ethical responsibility to protect patient privacy. Information regarding patients must not be released, disclosed, or discussed either inside or outside the hospital.

There are laws, both state and federal, safeguarding patient records and penalties for the release of confidential information without patient authorization. I understand all may result in punitive action including possible termination fine or imprisonment.

As a volunteer I will consider all confidential information that I hear about patients, families, or hospital personnel as private. I will preserve family privacy by refraining from questioning staff, children, or families about a child's diagnosis. I will not discuss a child's medical condition unless the child or family initiates a discussion.

* I agree

Background Check

I certify that the information given by me in this application is true and complete. I understand that any false information, misrepresentation, or concealment of fact is sufficient grounds for my immediate discharge by St. Jude at any time.

I understand and agree that all information furnished in my volunteer application may be verified by St. Jude or, at St. Jude's request, by a third party. I further authorize all individuals and organizations named or referred to in this application and any records repository, and law enforcement organization to give St. Jude all information relative to my education, employment, work habits, standing, and capacity, character, general reputation, personal characteristics, mode of living, social security number trace history, driving record, government lists of excluded, debarred, sanctioned, or prohibited individuals, records of abuse registries, and any criminal record, and full criminal background check. I understand that this information will be used to determine my eligibility or continued eligibility to volunteer at St. Jude. I hereby release such individuals, organizations, and St. Jude from any liability for any claim or damage which may result. I hereby waive any claim for loss or damage suffered by me against St. Jude with regard to the submission of my personal information to St. Jude.

This authorization will remain in effect before, during, and throughout my volunteer or other relationship with St. Jude unless I withdraw this authorization in writing. This means that St. Jude is authorized to run any of these checks at any time during my volunteer or other relationship with St. Jude.

I understand that this document discloses to me that a consumer report may be obtained for volunteering purposes as part of the pre-selection background investigation and at any time during my volunteering for St. Jude. I may request a copy of any report prepared regarding me, including a written summary, and may also request the nature and substance of all information about me contained in the files of the consumer-reporting agency, if I provide proper identification. I understand that I may inquire as to the identity of those reporting agencies contacted and St. Jude will advise me of their identity so that I may direct my requests for information to them. St. Jude or the reporting agency will provide information on and the nature and scope of information they furnished.

I have carefully read the above Permission to Conduct Background Check, and I understand and agree to all statements.

* I agree

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