St. Jude Children's Research Hospital Volunteer Participant Agreement

After completing this form, please complete the Volunteer Services Competency Test.

Asterisk (*) indicates a required field.

First Name*

Last Name*

I have requested to be a volunteer participant at St. Jude Children's Research Hospital, Inc. ("St. Jude") for the Volunteer Program. I understand that my services as a volunteer participant are important to the research, education, and outreach of St. Jude.

I agree to treat all information that I may hear about patients, families, or hospital personnel as confidential. I understand that Federal law protects patients from having their personal health information impermissibly used or disclosed and that the breaking of confidentiality could result in my immediate dismissal as a volunteer. I understand that confidentiality is essential to the effective functioning of any department that utilizes volunteers.

I agree to serve as a volunteer as agreed to by the Volunteer Coordinator and myself. I understand that my services are that of a volunteer and not as an employee of St. Jude. My services are given without contemplation of future employment, and are given for humanitarian, religious, or charitable reasons. In some instances, I understand I may receive a stipend to defray costs associated with participation but it is not considered income.

I agree to notify the volunteer office and my volunteer supervisor if I am unable to work as scheduled. I will not report to work with a temperature of 38.0°C (100.4°F) or greater, measles, mumps, chicken pox, shingles, boils, infected lesions of the hands, streptococcal pharyngitis ("strep throat") or conjunctivitis (pink eye) or have cold or flu-like symptoms (cough, runny nose, sneezing).

I have been instructed in and understand the Universal Precautions policy and the safety procedures in place at St. Jude and will conduct myself accordingly. I understand that as a volunteer I am covered under an accident insurance policy provided by St. Jude, except when I fail to follow St. Jude's policies, as well as the particular instructions for the research/clinical study areas. I have been informed that hazardous biological and chemical materials, including radioactive substances, are used in the research area at St. Jude, and I agree to adhere to all applicable safety guidelines.

I agree to abide by the policies and procedures set forth in the St. Jude Children's Research Hospital Volunteer Orientation Manual, including St. Jude's Fire Plan R.A.C.E. I fully understand the Infection Control policies and procedures and any additional information provided to me by my department supervisor and other St. Jude personnel. Other areas included in orientation are age-specific competencies, ergonomics, life safety and utilities management, substance abuse, electrical safety, security, information management and the patient abuse policies.

I understand St. Jude will hold harmless and defend me against third-party claims based on services I perform, in good faith as part of my authorized responsibilities under this Agreement.

I understand that the Volunteer Services Office reserves the right to terminate my volunteer status as a result of:

a. failure to comply with St. Jude policies, rules and regulations

b. absences without prior notification

c. unsatisfactory attitude, work or appearance

d. any circumstances which, in the judgment of the Volunteer Services Office would make my continued services as a volunteer contrary to the best interests of St. Jude

It is also understood that I may terminate my services as a volunteer if I become unable to continue my services under this Agreement.

My initials below acknowledge that I understand the obligations imposed upon me by this Agreement, and I agree to comply with all the terms of this Agreement.

Initials*

Date Submitted*

I agree to share this information with St. Jude*
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