DAISY Award

 

 

  • Family Centered Care Volunteer Application

    Asterisk (*) indicates a required field.
  • APPLICANT CONTACT INFORMATION

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  • PATIENT INFORMATION

  • DEMOGRAPHICS

    The following information is optional, and will help us ensure we have broad family participation in our Family Centered Care program.
  • EDUCATION

  • EMPLOYMENT

    Please list current and/or most recent two positions held.
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  • EMERGENCY CONTACT

    In case of emergency, please notify:
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  • REFERENCES

    Please provide the names and contact info of two individuals who would be willing to give a character reference. A preferred reference is someone who has known you more than three years and is not a relative.
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  • FCC AREAS OF INTEREST: Please check all that apply.

  • AVAILABILITY

  • SKILLS

    Please let us know if you have any special skills you would like to share.
  • GETTING TO KNOW YOU

    Please limit all responses to 500 characters.
  • CONFIDENTIALITY: Please read and inital at the bottom indicating that you have read and agree to the following:

  • I understand and agree that in the performance of my duties as a Family Centered Care Advisor at St. Jude Children's Research Hospital, I must hold ALL patient and family information STRICTLY CONFIDENTIAL. Hospital 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 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 FCC program.

  • 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.

    I understand and agree that all information furnished in this application may be verified by St. Jude. I hereby authorize all individuals and organizations named or referred to in this application and any records repository, or law enforcement organization, to give St. Jude all information relative to my employment, work habits, character, credit history and any criminal record and hereby release such individuals, organizations and St. Jude from any liability for any claim or damage which may result. 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 and the nature and scope of information they furnished.

    I understand and agree that my birthday and social security number, along with my other personal information, are voluntarily being submitted by me electronically via the World Wide Web to St. Jude on this Volunteer Service Application. If I chose not to submit this information electronically, I may call the Volunteer Services Department at St. Jude and provide this information over the telephone. I further understand and agree that information related to my birthday and social security number may be used for the purpose of a criminal record check if I become a final candidate for volunteering. 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.

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