Housing and Patient Services 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 commit to at least one volunteer shift per week.

* 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.

What housing facility are you interested in?

Contact and Personal Information

* First Name

Middle Name

* Last Name

First Name (preferred)

* Local Address

Apt. or Ste. #

* City

* State/Province

* Zip Code

* Main phone

Alternative phone

* Email address

* Date of Birth

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?

* If yes, 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

Zip (US)/Postal (CA)

Country code (by name)

Emergency Contact

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

* First and Last Name

* Relationship name

* Main 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 locations that apply

Are you currently employed by the selected location?

* Please list the department(s) in which you are (or were) employed.

* Start date

* End date

* 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's full name

Patient MRN #

Volunteer Experience

Do you have any previous St. Jude Volunteer Experience?

Please list any previous volunteer experience. Include location, supervisor's name and length of time you volunteered.

Previous Experience (1)

Name of Organization

City

State

Dates Served

Main phone

Email address

Previous Experience (2)

Name of Organization

City

State

Dates Served

Main phone

Email address

Help us get to know you.

* 1. Why are you interested in being a volunteer at St. Jude? What would you like to gain from this experience?

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

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

* 4. Tell us about you: do you have any special skills, interests, or hobbies?

5. Please describe experience with St. Jude other than as a hospital volunteer:

6. How did you hear about volunteering with St. Jude?

If you selected 'other,' please give further details here. If you selected 'Current St. Jude volunteer,' tell us who so we can thank them!

 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.  

Availability

Please indicate your availability below. While we strive to meet your schedule needs, please know that we cannot guarantee that there are positions to fit your availability.

Day and time availability

Sunday Morning

Sunday Afternoon

Sunday Evening

Monday Morning

Monday Afternoon

Monday Evening

Tuesday Morning

Tuesday Afternoon

Tuesday Evening

Wednesday Morning

Wednesday Afternoon

Wednesday Evening

Thursday Morning

Thursday Afternoon

Thursday Evening

Friday Morning

Friday Afternoon

Friday Evening

Saturday Morning

Saturday Afternoon

Saturday Evening

Commitment

Are you aware of any reason that would prevent you from volunteering on a consistent basis (a minimum 3 times per month for a miniumum of 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 the department of Housing and Patient Services at 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, credit agency, and law enforcement organization to give St. Jude all information relative to my education, employment, work habits, credit worthiness, standing, and capacity, character, general reputation, personal characteristics, mode of living, social security number trace history, driving record, government lists of excluded, debarred, sanctioned,
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 of my rights under the Fair Credit Reporting Act, 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 credit 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 Credit Check/ 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)