Hospice Volunteer Application

Must be 18 years of age or older.

Volunteer Experience:

(Fill this out if you're a new volunteer)

Other Information:

Volunteer Agreement

If accepted as a volunteer for St. Charles Health System, I agree to the following:

1. I will hold all information that I may obtain directly or indirectly concerning patients, doctors or staff, as absolutely confidential and will not seek to obtain information from patients. In addition, I will not solicit my political or religious beliefs to patients, their families and/or staff.
    
2. My services are donated to the hospital without contemplation of compensation or promise of future employment.
    
3. I will submit to medical screening which may include: TB skin test and/or immunizations that may be necessary as part of my volunteer assignment.
    
4. I understand I must comply with the Universal Masking Policy that all St. Charles employees must follow. Here is a summary:

   Summary of Masking and Source Control Requirements
   	Direct Patient Care	Healthcare Setting (non-direct patient care)	Non-Healthcare Setting
   Unvaccinated	N95 or higher filtering facepiece respirator	Medical Grade Procedure Mask	Medical Grade Procedure Mask if no physical distancing; or No masking required when physical distancing
   Vaccinated	Medical Grade Procedure Mask	Medical Grade Procedure or Source Control Mask	No masking required

5. I understand that a criminal background check will be required prior to beginning volunteer service.
    
6. I agree to commit to my volunteer position for a minimum of three months.
    
7. I will be punctual and conscientious; conduct myself with dignity, courtesy and consideration of others; and endeavor to make my work professional in quality.
    
8. I will make every effort to resolve any problems related to my volunteer assignment with my supervisor and the volunteer coordinator.
    
9. I will make my best effort to fulfill my commitment to St. Charles Health System by completing all volunteer assignments that I accept.
    
10. I understand that the Volunteer Services Department reserves the right to terminate my volunteer status as a result of failure to comply with hospital policy; absences without prior notification; unsatisfactory attitude, work or appearance; or any other circumstance which in the judgment of the volunteer coordinator, would make my continued service as a volunteer contrary to the best interests of the hospital.
     
11. I understand that it is a violation of the health system’s policy to solicit business or act as an agent for outside business or to solicit business from patients or staff.
     
12. I will not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on hospital property, unless I receive the express authorization of the volunteer coordinator.
     
13. I will comply with the Gift and Gratuity Policy at St. Charles which states, "Caregivers are to refrain from accepting goods and services from patients, their friends and their families. Small gratuities such as boxes of candy, cards and flowers may be accepted from patients or visitors who wish to provide a token of appreciation, but no type of gratuity or gift should ever be solicited by a caregiver. Similarly, caregivers are not to give personal gifts to patients. Any patient or visitor wishing to make a cash gift to the hospital may be directed to the Foundation or any other charity of the patient’s or visitor’s choice."

I agree to the above conditions and consent to and authorize St. Charles Health System to complete a criminal background check.