St. Jude Children's Research Hospital Volunteer Application

Please check all of the true statements:

* I currently reside within 50 miles from 262 Danny Thomas Place, Memphis, TN 38105.

* I am interested in an individual volunteer placement.

* I am 18 or older.

* I am not enrolled in high school.

* I am able to make the required minimum 8-month commitment.

* I am not volunteering to perform court-ordered service or short term community service hours.

* I am able to communicate effectively in English.

* I am able to walk, stand, bend, and do some light lifting for 2-4-hour shifts.

* I have a vaild social security number.

Are you applying to be a Eucharistic Lay Minister?

* Please upload your Licensed Extraordinary Lay Minister of the Eucharist Certification

Are you applying to the Pet Therapy or R.E.A.D. Programs AND have been approved by St. Jude staff to complete this application? (If you have not already been approved to proceed with the application, please reach out to volunteers@stjude.org prior to completing this form. Once approved, a member of St. Jude staff will provide you with the proper paperwork to complete and upload here.)

When you have completed this application, you will be directed to another page to create a dog profile and upload the required documents for your dog(s).

Dog's birthday (if unkown, when do you celebrate it?):

* Please upload your Handler Card

* Pet Handler Card Expiration Date:

Contact and Personal Information

* First Name

Middle Name

* Last Name

First Name (Preferred)

* Local Address

Apt. or Ste. #

* City

* State

* Zip Code

* Cell Phone

Alternative Phone

* Email Address

* Date of Birth

Race

Race - Multiracial expanded

American Indian or Alaskan Native

Asian

Black/African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White/Caucasian

Prefer not to disclose

* Race expanded

* Ethnicity

* Ethnicity-Additional

Gender

Primary Language

Additional Languages

Will you need an accommodation?

* If you need an accommodation while volunteering, please describe:

Criminal History

Have you been convicted of a felony?

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

Education

Highest Level of Education

Are you currently enrolled in school?

School

Classification

Current Major/Course of Study

Expected Graduation Date

Permanent address

Does your permanent address differ from your local address?

Please share your permanent address below.

* Permanent Address

Apt. or Ste. #

* City

* State/Province

* Zip (US)/Postal (CA)

Country

Emergency Contact

Please let us know who to contact in the event of an emergency.

* First and Last Name

* Relationship

* Primary Phone

Alternative Phone

E-mail

Employment

Are you currently employed?

* Name of Organization

* City

* State

St Jude, ALSAC, or Children's GMP Employment

Are you currently or have you ever been employed by St. Jude Children's Research Hospital, ALSAC, or Children's GMP, LLC?

If yes, please select all that apply.

Please list the department(s) in which you are (or were) employed and your dates of employment.

* Department

Are you currently employed by St. Jude or related employer?

* From

* To

* Supervisor

Employee ID

Additional information you would like to share:

Patient Relation

Our policy states that patients/families/relatives may apply if it has been greater than one year from the patient's first scheduled off-therapy treatment. Infectious Disease/Hematology patients/families/relatives are eligible to volunteer one year from the day they are transferred to adult provider status. Parents and relatives of ACT (after completion of therapy) patients are eligible to volunteer. Family members of deceased patients must wait one year before volunteering. Please indicate if you have ever been a patient or relative of a patient and how long it has been since treatment.

Are you a current or former St. Jude Children's Research Hospital patient or are you related to a current or former St. Jude Children's Research Hospital patient?

Relationship to Patient

How long has it been since treatment?

* Patient Full Name

Patient MRN #

Volunteer Experience

Do you have previous St. Jude Volunteer Experience?

Please list any previous volunteer experience. Include location and length of time you volunteered.

Name of Organization (1)

City

State

Dates Served (From - To)

Name of Organization (2)

City

State

Dates Served (From - To)

Name of Organization (3)

City

State

Dates Served (From - To)

Help us get to know you.

* 1. Why are you interested in being a volunteer with St. Jude?

* 2. What do you hope to gain from this experience?

* 3. How would you handle the stress and emotions that come from working with children who have life-threatening illnesses?

* 4. As a volunteer, how do you see yourself helping to improve the experience for patients and families?

* 5. Tell us about yourself. Do you have any special skills, interests, or hobbies?

More Information

1. Most placements require that volunteers work independently. Is this something that you feel comfortable doing?

2. Every shift varies from week to week and day to day. You may find that there is downtime during your shift. Are you comfortable with downtime?

3. Have you had an experience or personal loss within the last 12 months that would impact your ability to serve in the hospital?

If so, please share:

4. Do you have any specific challenges or limitations that you wish to disclose?

If so, please share:

How did you hear about volunteering at St. Jude?

Other (please specify):

Connection to St. Jude Children's Research Hospital

Please tell us about any personal connections you have with St. Jude Children's Research Hospital, its volunteers, or its employees.

Do you have a friend or family member who works for or volunteers with St. Jude Children's Research Hospital, past or present?

* Name(s) and Relationship:

Availability

Please indicate your current availability below. We strive to match your interests and our needs; however certain shifts may be limited. Please know that we cannot guarantee that there are positions to fit your schedule. Shift times vary between 2-3 hours. The time frames below do not indicate specific volunteer shifts, but they will aide staff with your potential placement.

Day and time availability

Monday Morning (9 a.m - 12 p.m.)

Monday Afternoon (12 - 4 p.m.)

Monday Evening (4 - 9 p.m.)

Tuesday Morning (9 a.m - 12 p.m.)

Tuesday Afternoon (12 - 4 p.m.)

Tuesday Evening (4 - 9 p.m.)

Wednesday Morning (9 a.m - 12 p.m.)

Wednesday Afternoon (12 - 4 p.m.)

Wednesday Evening (4 - 9 p.m.)

Thursday Morning (9 a.m. - 12 p.m.)

Thursday Afternoon (12 - 4 p.m.)

Thursday Evening (4 - 9 p.m.)

Friday Morning (9 a.m - 12 p.m.)

Friday Afternoon (12 - 4 p.m.)

Friday Evening (4 - 9 p.m.)

Saturday Morning (9 a.m. - 12 p.m.)

Saturday Afternoon (12 - 4 p.m.)

Saturday Evening (4 - 7 p.m.)

Sunday Morning (9 a.m. - 12 p.m.)

Sunday Afternoon (12 - 4 p.m.)

Sunday Evening (4 - 7 p.m.)

Commitment

Are you aware of any reason that would prevent you from volunteering on a consistent basis (a minimum 3 times per month for 8 months)?

* If yes, please explain:

Understanding/Agreement

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

Termination

I understand and agree that my volunteer services can be terminated with or without cause and without notice at any time at the option of either St. Jude or myself.

* I agree

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I Agree (Signature Box)