McLaren Central Michigan Volunteer Services - Application - Confidentiality - Authorization - Release Forms

McLaren Central Michigan Volunteer Services Application, Confidentiality and Authorization and Release Forms

Note: Fields marked with an * indicates required field

Volunteer Opportunity you interested in: *

Gift Shop	Surgical Waiting Area
Welcoming Guests at Entrance

I hereby request to become a member of the Volunteer Services Department at McLaren Central Michigan and will abide by all hospital and department policies. I am willing to volunteer and:

am 18 years of age or older.
agree to complete the orientation, and to be trained and oriented to the tasks & functions to which I am assigned,
wear a volunteer uniform and ID badge and accurately record my service hours,
receive a tuberculosis (TB) Test prior to beginning my volunteer duties, if I do not have documentation of receiving one in the past 12 months; an annual Influenza Vaccination is recommended (if volunteering during the months of October – March); COVID-19 Vaccination is recommended or appropriate declination form completed; and comply with any other mandatory requirements,
will be responsible and regular in my attendance and will inform my department of necessary absences,
understand that my services are donated without contemplation of compensation or future employment and does not constitute an employment contract,
understand my assignment can be terminated at any time with or without notice and for any reason,
will respect the need for safety, infection control, and patient confidentiality,
understand that my volunteer work experience will be recorded and held for future reference. I give my permission for release of this information,

First Name: *

Last Name: *

Middle Initial: *

Street Address: *

City - State - Zip Code: *

Cell Phone Number: *

Home Phone Number: *

Email Address: *

Michigan Driver License Number: *

Date of Birth - mm-dd-yyyy: *

Please indicate any medical, physical or mental handicap that would affect your ability to perform volunteer duties? *

Please indicate if you are affiliated with McLaren Central Michigan? *

Please indicate if you are preparing for any special career or have training in any special area? *

Are you at least 18 years of age - Adult Volunteer? *

yes

Are you eligible to work in the U.S.? *

yes

High School Graduate?

yes

Education - Training:

College or Number of years attended:

Degree or Degrees earned:

Associate

Bachelors

Masters

Phd

Work Experience

Are you currently employed?

yes

Currently employed at or retired from?

Days or times you work:

Employer Phone:

Does your employer have a volunteer giving program?

yes

Do not know

Previous Work Experience:

Local person to be contacted in case of illness/emergency:

Contact Name: *

Relationship to you: *

Contact Phone Number: *

Contact Address: *

Contact City - State - Zip Code: *

References (Please list two adults over 21 years who are not relatives and who have known you for at least two years.)

Name:

Phone Number:

Street Address:

Reference City - State - Zip Code:

Name:

Phone Number:

Street Address:

Reference City - State - Zip Code:

Volunteer Profile

Please give a brief summary of your background:

Reasons for wanting to volunteer:

How did you learn about volunteer opportunities?

Is this a required volunteer assignment?

yes

If yes, number of hours needed:

If yes, deadline:

Times and days available:

Skills:

Computer	Cash register
Languages	Musical Instrument

Other Skills

Other skills, interests or community affiliations:

Have you ever been convicted of a felony or a misdemeanor? *

yes

If yes, please indicate the nature and date of occurrence.

I have read and understand the information listed below. Should I need medical attention during or as a result of my volunteering experience, I assume full responsibility for any treatments deemed necessary. I assume responsibility of all medical costs which result and release McLaren Central Michigan of all liability. While I am volunteering at McLaren Central Michigan, I realize that all health care information, patient and records are a confidential matter. All information exchanged while I am volunteering must be held in the strictest confidence. My typed name below shall have the same force and effect as my written signature.

Applicant Signature: *

Date: *

Please read the following information prior to submitting your application:

Infection Control

Proper hand hygiene helps prevent the spread of infections from one person to another. Hand hygiene products, which contain a special antibacterial agent, are available in wall dispensers in the work areas and cafeteria.

Hazardous Materials

Potentially hazardous chemicals and materials are used in certain areas as part of the daily operation of a department. Material Safety Data Sheets (MSDS) which describe the hazard and handling instructions for all chemical products are available for your review on request.

Tobacco Free Campus

Smoking and all tobacco products are prohibited in all McLaren Central Michigan facilities, its adjacent grounds, and in hospital-owned vehicles.

Dress Code

Please adhere to the following dress code, unless otherwise directed:

Comfortable closed-toe shoes with socks or hose, no bare legs
Shirt (no slogans with the exception of logo wear) no t-shirts, low-cut or midriff-baring shirts
Pants (no sagging pants) or Skirts (may not be more than 2” above knee)
No fragrance or smoking odor on clothing
No flip-flop / beachwear type shoes
ID badges must always be worn and be located above the waist

You must be in good health without fever (99.0 or less) and/or symptoms of cold, flu or other illness. Confidentiality Please read and sign the attached confidentiality agreement.

Statement of Confidentiality

Each of our patients and employees has the right to expect that we will keep any knowledge we have about them in the strictest confidence. It is our obligation under the law and the codes, regulations and certifications under which we operate, to honor this expectation. Equally important, respecting confidentiality is part of our obligation to provide the most comfortable and caring environment for our patients.

We live at a time when personal information is recorded in many forms. It may be on paper, but it may also be found on a computer screen, voice mail, cellular telephones or another modern convenience. This data is all subject to the same rules.

Our expectation is that you will keep all patient and employee information to yourself or share it only with others who have a work related or legal right to know. You should never share any information with anyone else, including spouses or coworkers. Passwords, to access patient and employee information, must not be shared.

Finally, we remind you that the organization will not tolerate violations of this standard. The established rules call for prompt and severe discipline for a breach of confidentiality. Please understand that the Access and Confidentiality Agreement will be strictly enforced.

Full Name - my typed name shall have the same force and effect as my written signature: *

Date: *

Authorization and Release

In connection with my opportunity to participate in any program affiliated with McLaren Central Michigan, I understand that information may be requested as to my character and other personal history. I further understand that you will be requesting information regarding my criminal history and other public records. I agree that any false information may subject me to removal from programs at McLaren Central Michigan. It is the policy of McLaren Central Michigan not to employ or retain persons in positions of trust who have demonstrated a propensity to engage in illegal activities.

I hereby authorize and release from all liability without reservation, McLaren Central Michigan and any law enforcement agency, administrator, state/federal agency, institution, insurance company, or person gathering or furnishing the above information.

Full Name - my typed name shall have the same force and effect as my written signature: *

Date: *

Past Proper Name or Names - i.e., Maiden Name:

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