Patient Family-Centered Care Volunteer Application

If you are a caregiver, family member of a St. Jude patient or former patient and want to contribute to our Patient Family-Centered Care (PFCC) program, you may participate in a variety of ways, depending on the amount of time you can offer and your unique experiences related to care at St. Jude. Whether you are available for an afternoon or can commit to a monthly meeting, we have a way for you to join our efforts.

Asterisk (*) indicates a required field.

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

Applicant Information

Title*

Dr. Ms. Mrs. Mr.

First Name*

Middle Name

Last Name*

Preferred Name

Other Legal Names Used

Date of Birth*

Relationship to the patient*

Contact Information

Main Phone Number*

Work Phone Number

Email Address*

Address 1*

Address 2

City*

State/Province/Region*

Country*

Zip/Postal Code*

Patient Information

First Name*

Middle Name

Last Name*

Medical Record Number*

Date of Birth*

Treatment Status*

On-therapy Off-therapy ACT/Alumni status Deceased

If patient is on-therapy, indicate the anticipated date of completion of therapy

If patient is off-therapy, indicate how often routine follow-ups occur.

Getting to Know You

Responses limited to 500 characters.

1. How comfortable do you feel stating your ideas and opinions and discussing differences with other families, staff and in a group?*

2. How comfortable would you feel providing feedback from other families' perspectives in an objective manner?*

3. What strategies would you use to ensure that the information you hear and discuss through PFCC activities remains confidential?*

4. Please discuss any reason that would prevent you from serving as a PFCC participant volunteering on a consistent basis or might limit your ability to volunteer at St. Jude?*

5. Please ask us any questions, discuss concerns, or make comments

Confidentiality

I understand and agree that in the performance of my duties as a Patient Family-Centered Care Advisor at St. Jude Children's Research Hospital, I must hold ALL patient and family information STRICTLY CONFIDENTIAL. Hospital Patient Family-Centered Care Advisors have a legal and ethical responsibility to protect a patient and their family's privacy. Confidential information includes, but is not limited to a patient's diagnosis, treatment and current medical status, as well as information about the patient and their family's social history and overall experience here at St. Jude. I agree that I will not discuss or disclose any confidential information I may learn about as a Patient Family-Centered Care Advisor with anyone, either here at St. Jude, or outside the hospital. I understand that if I violate a patient or the family's confidentiality, I may no longer be able to participate in the PFCC program.

Initials*

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, 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 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.

Initials*

I agree to share this information with St. Jude*
This Service is governed by and operated in accordance with US law. If you are located outside of the US, you use this Service voluntarily and at your own risk. If you choose to submit personal data like your name and email address, please note that your Information will be transferred to and processed in the United States. By checking this box while using this Service, you acknowledge that the data protection and other laws of other countries, such as the United States, may provide a less comprehensive or protective standard of protection than those in your country, and consent to your Information being collected, processed and transferred as set forth in the Privacy Policy and US law.