Welcome to the Sparrow Hospital Volunteer Services Department

Teen Volunteer Application - Year Round Program 10-16

Teen Volunteer Application for Year Round Program
Volunteer Contact Information
First name
Middle name
Family/last name
Street Address (Include Apartment # if applicable)
City
State
Zip/postal
Mobile
Home phone
Teen Volunteer E-mail
Age
Date of Birth
Name of High School
Graduation year
Emergency Contact/Parent or Guardian Information
Parent or Guardian's Name
Mobile Phone
Home phone
Address
City
State
Zip/postal
E-mail
Allergies and significant medical conditions we should be made aware of to ensure the teen is successfull
Please provide a second emergency contact should the first person not be available
Name
Mobile
Home phone
If this information should change while your teen is serving with us, please be sure to update with the Volunteer Services Department.
Past Volunteer Experience
Activity/Organization
Dates:
to
Major Responsibilies
Past Employment
Employer's Name
Dates:
to
Describe duties
Extra Curricular Activities
Activities and dates (Volleyball, Sept.- Nov.; Musical, Jan-Feb.)
Do you currently have a paid job?
If yes, how many hours a week do you work?
What motivated you to seek volunteer opportunities at Sparrow?
What do you want to achieve from you volunteer experience?
Selecting positions: Please review the positions descriptions listed online and give your top three choices:
First choice
Second choice
Third choice
What day and time frame works best for you to volunteer? For example: Monday between 4-6 or 6-8. This is a good item to discuss with a parent or guardian to ensure you have transportation.
Are you able to serve at least one year and make a weekly commitment to a two hour shift?
Have you ever been convicted of a misdemeanor or felony?
If yes, please explain.
Do you use nicotine products?
Nicotine-free Volunteer Policy Statement:
To further our mission in providing quality, compassionate care to everyone, every time, effective April 1, 2012, Sparrow Health System will no longer offer volunteer placements to potential volunteers who use tobacco or nicotine products in any form. Sparrow promotes a healthy and safe environment for all Associates, Physicians, Volunteers, Patients and Visitors.

A nicotine user is any individual who uses nicotine products including, but not limited to, cigarettes, cigars, pipes and chewing tobacco. This policy also applies to e-cigarettes, which are regulated by the Food and Drig Administration as a nicotine product. Nicotine patches and gum are also included.
Acknowledgement of Sparrow Health System CONFIDENTIALITY AND SECURITY OBLIGATIONS AND/OR CONDITIONS

As an Associate, physician, healthcare provider, contractor, or temporary employee or volunteer of a Sparrow Health System entity, you may have access to confidential information including patient, financial or business information obtained through your association with Sparrow Health System. The purpose of this Acknowledgement is to help you understand your personal obligation regarding confidential information.

Confidential information includes any information about a person's past, present, or future physical or mental health; the health care services provided to the individual or payment information related to such services, that identifies the individual or provides enough information that there is a reasonable basis to believe the information could be used to identify the individual.

Confidential information is valuable and sensitive and is protected by law and by strict Sparrow Health System policies. State law and the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), require protection of confidential health information. Inappropriate disclosure of confidential health information regarding patients may result in the imposition of fines on Sparrow Health System of up to $250,000 and ten years imprisonment per incident.
Accordingly, by signing this Acknowledgement and, having as a condition of and in consideration of my access to confidential information whether in oral, paper, electronic, or any other form, I acknowledge the following obligations and conditions of employment:

1. I am only allowed to access confidential information for which I have a legitimate need to know as part of my job responsibilities at Sparrow Health System and am only allowed to access information systems for which I am an authorized user. I am prohibited from removing any confidential information from Sparrow premises in any media including paper, magnetic disk, compact disk, video, recording, etc. without the express written permission of an authorized officer of Sparrow Health System. In addition, if I have remote access to Sparrow Health System information systems, I will not download or transfer any confidential files or data to my home personal computer.

2. I am prohibited from using or connecting to the personal computer assigned to me by Sparrow Health System, any equipment, modem, other hardware, or software without the prior written approval of Sparrow Health System -Information Services.

3. I am prohibited from discussing confidential information in any location at Sparrow Health System where it is likely that the conversation can be overheard by people who do not have a legitimate need to know the confidential information in order to perform their job responsibilities at Sparrow. I am required to return all recorded confidential information to its authorized, secure location in Sparrow Health System when I am done with it. I am prohibited from in any way from divulging, copying, releasing, selling, loaning, reviewing, altering or destroying any confidential information unless expressly permitted by existing policy or as properly approved in writing by an authorized officer of Sparrow Health System within the scope of my association with Sparrow Health System.

4. I am prohibited from utilizing another person's password in order to gain access to any information system. I am prohibited from revealing my computer access code to anyone else unless a confirmed request for access to my password has been made by Information Services and I am able to confirm the legitimacy of the request and the requestors. I am required to change my password immediately after it is disclosed to anyone. I am personally responsible for all activities occurring under my password.

5. If I observe or have knowledge of unauthorized access or divulgence of confidential information I am obligated to report it immediately to my supervisor or to Sparrow Information Security.

6. I am prohibited from seeking personal benefit or permitting others to benefit personally by any confidential information that I may have access to.

7. I acknowledge and recognize that I am prohibited from operating any software on the personal computer assigned to me by Sparrow Health System, other than those programs provided to me by Information Services, without the prior written approval of my supervisor.

8. I acknowledge that all information, regardless of the media on which it is stored (paper, computer, videos, recorders, etc.), the system which processes it (computers, voice mail, telephone systems, faxes, etc.), or the methods by which it is moved (electronic mail, face to face conversation, facsimiles, etc.) is the property of Sparrow Health System and shall not be used inappropriately or for personal gain. I also acknowledge that all electronic communication shall be monitored and subject to internal and external audit.

9. I acknowledge that my failure to fulfill the obligation or conditions in this Acknowledgement may result in disciplinary action, which might include, but is not limited to, termination of employment or, loss of my privileges within Sparrow Health System or other legal action.

By my signature below, I acknowledge that Sparrow Health System has an active on-going program to review records and transactions for inappropriate access and I acknowledge that inappropriate access or disclosure of confidential information contrary to or inconsistent with the conditions described in this acknowledgement can result in penalties up to and including termination of my employment and/or legal action against me.
Signature
Date

Teen Parental Approval

I hereby give my consent to have my son/daughter to be a Teen Volunteer for Sparrow Healthy System and to receive an annual TB skin test for as long as he/she remains active in the volunteer program. I also authorize the Sparrow Health System Emergency Department physician and those physicians or personnel as he/she may designate to provide the above named patient all necessary medical care and treatment, including surgical intervention, if necessary, on behalf of my minor child.

Relationship to Child
Telephone
Date
Parent/Responsible Relative/Legal Guardian, my typed name shall have the same force and effect as my written signature
Thank you for your interest in Sparrow's Volunteer Services Teen Program. We will send you a confirmation email immediately following the submission of this application. Please keep it and review for next steps.

Review of next steps:

1. Application is complete
2. Get a TB test and bring verification to the interview
3. Between November 1 and March 31st get the flu vaccine and bring us verification to the interview
4. Complete the online orientation that will be sent to you in the confirmation email
5. Sign up for a tour and interview using the link that will be in the confirmation email