Dear Prospective Volunteer:

Thank you for your interest in volunteering with AtlantiCare. Volunteers are an important part of our team whom we identify as VIP’s – Volunteers in Partnership. Volunteers provide support in the Medical Centers and satellite offices to help deliver exceptional service to the communities we serve. We are grateful that you will share your talents with us, and want your experience as a volunteer to be a rewarding one.

Enclosed are the following documents which must be completed in full. Incomplete applications cannot be processed.

AtlantiCare Volunteer Application – Confidentiality Statement – Please be sure to include the complete names and addresses of three references whom are not related to you. All references are contacted by phone.

AtlantiCare Criminal Background Check Authorization for Consent and Release from Liability o This process may take up to five weeks for completion.

AtlantiCare Physician Medical Certification Form-Confidential Medical Information.  This form must be completed by your personal physician.**  If you don't have a personal physician, you are welcome to contact the AtlantiCare Access Center at 1-888-569-1000 and they may be able to assist you.  AtlantiCare does not cover any cost associated with the completion of the Physician Medical Certification Form. 

** PLEASE NOTE – a 2-step PPD test is required, immunity against Rubella and Rubeola, and Chickenpox immunity if you are volunteering in certain areas. If you have had a PPD test within the past year and/or have received the MMR vaccine, and Chickenpox vaccine, please obtain these records. You will need to take them to Occupational Medicine at for your scheduled appointment. If you do not have these proofs, we will provide the forms to be tested through AtlantiCare Occupational Health at no charge to you.

Please mail the completed forms to:AtlantiCare Regional Medical Center ATTN:  Volunteer Services

65 W. Jimmie Leeds RoadPomona, NJ 08240

ORyou may hand deliver the forms in an envelope addressed to Volunteer Services to the above Pomona address.

 When the background check is complete, and all references contacted, we will set up a mutually agreeable time to meet to discuss the volunteer opportunities available.  At that time we will take your photograph, and give you the AtlantiCare Occupational Medicine Authorization for Services form to have the following tests performed, unless you have proof of the PPD testing and documentation of required vaccines, which you must bring with you to your scheduled appointment. These tests are of no cost to you. 

2-Step PPD test screening for tuberculosis Rubella and Rubeola screening if no documentation of 2 MMR vaccines  Varicella screening if no history of chickenpox disease or documentation of vaccination T-dap vaccination may be required Drug Screening **PLEASE NOTE - If the test results indicate you are not immune to Rubella and Rubeola, and/or Varicella, the

required vaccination(s) must be arranged by you through your personal physician.  AtlantiCare does not pay for these immunizations. The Tdap vaccine and Chickenpox immunity is not required but may prevent you from volunteering in certain areas.

If all test results are returned negative you will be invited to participate in the AtlantiCare Orientation.

In addition, to stay active as an AtlantiCare volunteer, annual education and PPD testing are required.

Please call if you have any questions.

Thank you.

Sincerely,

Maureen HopeVolunteer Supervisor

AtlantiCare Regional Medical Center Mainland Campus - Volunteer Services Office65 West Jimmie Leeds Road • Pomona, New Jersey 08240 • Phone: 609-652-1000 ext. 27600 • Fax: (609) 652-3583

AtlantiCare is an equal opportunity employer. It is our policy and practice that all persons be treated without regard to protected classes under New Jersey and/or federal law

VOLUNTEER APPLICATION

Instructions: Please complete ALL parts on this application. Incomplete applications cannot be processed. Please call the Volunteer Office at 609-404-7600 if you have any questions. Thank you.

Date: _____________________________ Social Security Number:_________________________________

Name: _____________________ ________________________ Date of Birth: _______________________ (First) (Last) (Month & Day – Year is Optional)

Address:_________________________________________________________________________________

City:__________________________________ State:________________ Zip Code:___________________

Home Phone: __________________________Cell Phone:________________________________________

Business Phone: _______________________ E-mail Address: _____________________________________

Emergency Contact:

Name: ____________________________________________ Relationship: __________________________

Address: ________________________________________________________________________________

City:__________________________________ State:________________ Zip Code:____________________

Home Phone: __________________________ Business Phone: ___________________________________

► Have you ever been employed by the AtlantiCare Health System? No Yes

If yes, when and which department? _____________________________________________________

Do you have any relatives who are employed or volunteer at AtlantiCare? No Yes, If yes,

please list the name of the person, relationship to you, and the department they work in.

NAME RELATIONSHIP TO YOU DEPARTMENT

How did you hear about volunteering with AtlantiCare?_________________________________________

Please tell us why you would like to be an AtlantiCare Volunteer: (required)

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

AtlantiCare may have volunteer opportunities at the Health Park and Airport Commerce inEgg Harbor Township, at the Health Plex in Atlantic City, and Medical Centers in Atlantic City and

Pomona. Please check which locations you would be able to volunteer?

Health Park Airport Commerce Atlantic City Pomona

How would you like to volunteer with AtlantiCare? (Volunteer opportunities are based on department needs. Please check all areas of interest.)

Interacting with patients (e.g. visiting patient rooms, sitting with patients to offer companionship, delivery of supplies, hospitality cart) H.E.L.P. – Hospital Elder Life Program – working with hospitalized seniors Interacting with the public (e.g. information desk, hospital guide, registration, dietary) Medical staff support (e.g. assisting staff, assembling information packets, filing, inventory) Clerical Help (e.g. filing, laminating, computer data entry, phone support, mailings) Gift Shop Sales (e.g. pricing of items, stocking shelves, sales, cashier) Auxiliary (fundraising/community representatives of the hospital, $10 annual dues) Creative Arts and Healing Program (e.g. musicians, performers, licensed pet therapy, licensed Reiki, etc.)

Hospice ** helping patients and their families who are at end of life, either directly with the patients/families, or helping in the hospice office. PLEASE COMPLETE THE HOSPICE QUESTIONNAIRE form if you may be interested in this area of volunteering. It is mandatory to attend a one-time specialized training which is held at the AtlantiCare Hospice and Palliative office in Egg Harbor Township. The training is held on a Saturday from 8:00 a.m. to approximately 4:30 p.m. twice a year.

Other interests for volunteering? Please explain:______________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Volunteers are usually scheduled in four hour shifts. Please indicate your preference below:

8:30 a.m. to 12:30 p.m. 12:30 p.m. to 4:30 p.m. 4:30 p.m. to 8:30 p.m.

If you are unable to commit to these times, how many hours could you commit for a shift? ________________

Is your volunteering a short term commitment? No Unknown at this time Yes – If yes, please

explain:__________________________________________________________________________________

________________________________________________________________________________________

ARE YOU A VETERAN? No YES – Thank you for your service! Branch:________________________

Do you speak another language? No Yes – If yes, what languages?________________________

Have you ever been found guilty of a crime, disorderly persons offense or misdemeanor in this or any other state, (including traffic violations) or are there currently criminal, disorderly persons or misdemeanor charges or complaints pending against you that have not been fully discharged by pre-trail intervention or a conditional discharge?

No Yes – If yes, please explain below: (a yes response will not necessarily restrict you from volunteering)

If yes, please explain: ______________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please check off below ALL the skills or abilities that apply to you… Athletic/Fitness Crafts Filing Enjoys interacting with people Good listener Writing Proofreading/Editing Procurement of donations

Organizing Attention to Detail Phone/Receptionist Gardening/Floral Arranging Photography Artistic

Ordained Minister-What denomination?________________________________

Musician - What instrument(s):_____________________________________________________________________

Computer – please check below level of skill beginner intermediate advanced – please list programs in

which you are proficient:_____________________________________________________________________________

What other talents/skills/hobbies can you share? _____________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Please describe any previous volunteer experience. Include type of work and dates of involvement:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Education (please check the highest level completed):

Some or no High School College, please specify degree: __________________________

High School Graduate, please specify degree: ________________________

Some College/Professional/Technical School _____________________________________________

Please list any professional and/or community organizations to which you belong: _________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please provide information about employment experience, beginning with most recent / present experience:

Employer Name & Address: _______________________________________________________________

Position & Responsibilities: _________________________________________________________________

Employed From: ______________ Employed To: _________________

Employer Name & Address: _______________________________________________________________

Position & Responsibilities: _________________________________________________________________

Employed From: ________________ Employed To: _________________

Employer Name & Address: ________________________________________________________________

Position & Responsibilities: _________________________________________________________________

Employed From: ________________ Employed To: _________________

HOSPICE VOLUNTEER QUESTIONNAIREThe AtlantiCare Hospice team includes doctors, nurses, social workers, clergy, home health aids and volunteers. The team works with patients and their families to provide palliative and hospice care to those facing life-limiting illnesses. The team also provides grief support to surviving family and friends. No one is turned away, regardless of their financial situation.

Volunteers are a valuable part of our team. Their involvement in a patient’s care is refreshing as they go into a patient’s home as a friend to the patient and their family. A Hospice Volunteer’s schedule is flexible; therefore, PEOPLE WHO WORK FULL TIME, PART TIME, ARE RETIRED, LIVE LOCALLY YEAR-ROUND, SUMMER RESIDENTS, AND THOSE WHO TRAVEL are welcome to be a part of the team. There are a variety of ways of involvement in the program including visiting patients, delivering a handmade gift to the patients, working in the office, and providing telephone support to the bereaved. (If requested, a bereavement volunteer calls the bereaved once a month for up to 13 months following the death of their loved one. In addition to the hospice training, a separate training is held for anyone interested in becoming a bereavement volunteer.)

Hospice Volunteer Trainings are usually held twice at year on a Saturday at the AtlantiCare Hospice and Palliative Care office in the Airport Commerce Center, 6550 Delilah Road, Building 300, Suite 210 in Egg Harbor Township. The training runs from 8:00 a.m. to approximately 4:30 p.m. A continental breakfast, and lunch are served. Notification is sent approximately one month before the scheduled trainings to those who have expressed an interest.

PLEASE COMPLETE THIS FORM ONLY IF YOU ARE INTERESTEDIN BECOMING AN ATLANTICARE HOSPICE VOLUNTEER.

Print Name:_____________________________________________________ Date:_____________________________ Home Phone:___________________________________ Cell Phone:_________________________________________

E-Mail____________________________________________________________________________________________

Would it be suitable to communicate with you by e-mail? Yes No

1. How did you become interested in becoming a Hospice Volunteer?_________________________________________

_____________________________________________________________________________________________

2. Have you lost anyone close to you in your lifetime? Yes No How recent was/were your loss(es)?____________________ What was/were your relationship(s) to the deceased?____________________________________________________

In what way(s), if any, has/have this/these loss(es) impacted your decision to become a Hospice Volunteer?

______________________________________________________________________________________________

______________________________________________________________________________________________

3. What work or life experiences are you bringing to the role of Hospice Volunteer?______________________________

_____________________________________________________________________________________________

4. In what areas are you interested in Volunteering?

Direct Patient Care Bereavement Volunteer Office Help Computer Data Entry Fundraising

5. How far are you willing to travel to participate as a volunteer? _____________miles _____________minutes

6. Fear of animals? No Yes, If yes, what:________________________________________________________

7. Please list any allergies:__________________________________________________________________________

COMPLETE THIS PAGE ONLY IF YOU ARE INTERESTED IN HOSPICE

VOLUNTEERING

COMPLETE THIS PAGE ONLY IF YOU ARE INTERESTED IN HOSPICE

VOLUNTEERING

CONFIDENTIALITY STATEMENT

If accepted as a hospital/hospice volunteer, I agree that I will attend a hospital/hospice orientation, at which I will learn about policies and laws impacting my duties in the hospital/hospice, including legal obligations relating to patient privacy, and:

1. I shall not reveal the names of patients that I visit or come into contact with.

2. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, other volunteers, or personnel and not seek to obtain confidential information from a patient.

3. My services are given to a patient with humanitarian reasons, regardless of religious or race differences.

I HAVE READ EACH OF THE ABOVE CONDITIONS AND I AGREE TO BE BOUND BY THEM.

Please print your name:__________________________________________ Date:______________________

Your signature:_________________________________________________

REFERENCES – Not related to you (please list three): IMPORTANT! – Please contact your references and inform them that you are using them as references. Many people do not want to answer questions about others over the phone and refuse to provide a reference for that reason. Please provide a daytime and alternate phone number for your references. If we are unable to obtain references, we cannot process your application.

I, _________________________________, hereby give ARMC permission to contact my references. PLEASE PRINT YOUR NAME

Your Signature:_______________________________________ Date:______________________

1) Name: ________________________________________________ Years Acquainted:_______________ Mailing Address – Street:__________________________________________________________________________

City ______________________________________ State:____________________ Zip:_________________

Phone(s): ________________________________________ Relationship: ____________________________

2) Name: ________________________________________________ Years Acquainted:_______________ Mailing Address – Street:__________________________________________________________________________

City ______________________________________ State:____________________ Zip:_________________

Phone(s): ________________________________________ Relationship: ____________________________

3) Name: ________________________________________________ Years Acquainted:_______________ Mailing Address – Street:__________________________________________________________________________

City ______________________________________ State:____________________ Zip:_________________

Phone(s): ________________________________________ Relationship: ____________________________

Please sign below, attesting that all the information you have provided in this application is accurate. Signature: ___________________________________________________ Date: _____________________

CRIMINAL BACKGROUND CHECK

AUTHORIZATION FOR CONSENT AND RELEASE FROM LIABILITY

In connection with my application for volunteer engagement with AtlantiCare, I hereby authorize AtlantiCare to conduct a background investigation on me. I understand that such an investigation could include, but is not limited to the use of a consumer report and criminal background check, a motor vehicle records check if applicable, and a military personnel records check. I understand that AtlantiCare may gather information which could include information from any present or former employer, reference provided by me, any school, law enforcement agency, local or county record office, licensing agency or other persons having personal knowledge about me, my character, my work history, reputation, personal characteristics and mode of living. I hereby authorize such an investigation and release AtlantiCare, its officers, directors, trustees, employees or agents from any and all liability arising from conducting the investigation, and preparing any reports relating thereto. This authorization for the release of information includes, but is not limited to, matters of opinion related to my character, abilities and past conduct. I authorize and request all persons, schools, businesses, credit bureaus, courts, law enforcement officers and agencies, motor vehicle agency, custodian of military records and licensing agencies to release such information without reservation, restriction or qualification. I understand that, if I am engaged as a volunteer at AtlantiCare, any false statements made by me will be considered as cause for dismissal. I understand that my selection, in part, is contingent upon the satisfactory results of a complete background investigation I hereby authorize AtlantiCare or its agents to conduct a background investigation. I hereby release AtlantiCare, it officers, directors, or any person and agency providing such information from any and all claims and damages connected with the release of any requested information. I agree that any copy of this document is as valid as the original and shall remain valid during the term of my volunteer work with AtlantiCare unless revoked by me in writing.

Please Print Name:_________________________________________________________________

Street:___________________________________________________________________________

City:____________________________________ State:______________ Zip:_________________

Signature: ________________________________________________________________________

Date of Birth: _____________________ Social Security Number: ___________________________

Driver’s License Number:____________________________________________________________

State Driver’s License Issued:_____________________ Expiration Date:______________________

Please print former name, if name changed through marriage or otherwise:

________________________________________________________________________________________ Parent’s Name (if under 18 years of age): __________________________________________________

Parent’s Signature (if under 18 years of age): _________________________________________________

Physician Medical Certification Form-Confidential Medical Information:

IMPORTANT: This form must be completed by your physician. If this form is not completed, your volunteer application will not be processed.

Your Name:______________________________________________________________________________

Your Address:______________________________________________________________________________

Dear Physician:

The individual noted above has applied for a volunteer position with AtlantiCare. Please complete the medical certification below:

My signature below certifies that the individual noted above is free of communicable disease and is able to fulfill the requirements noted in the Volunteer Role Description.

Physician’s Printed Name:___________________________________________________________________

Physician’s Address:________________________________________________________________________

Physician Signature:_________________________________________ Date:__________________________

____________________________________________________________________ ROLE DESCRIPTION

TITLE: Volunteer

JOB CODE: #815 EXEMPT:NON-EXEMPT: X

DATE: 3/31/98 REVISED:10/12 ( R )

POSITION SUMMARYThe Volunteer assists and supports hospital/hospice staff and management with patient care activities and administrative duties. Some hospital duties may include helping patients read letters, distributing reading material, transporting patients to and from therapy, and distributing gifts and flowers. Some hospice duties may include visiting patients to provide companionship, caregiver respite, or run errands for the families

This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to teamwork and cooperation.

QUALIFICATIONSEDUCATION: Successful Completion of hospital orientation required.LICENSE/CERTIFICATION: Current driver’s license & auto insurance required for Hospice direct patient volunteers. For specialized volunteer services current licenses/certifications are required.

EXPERIENCE: Prior experience with public contact required.

PERFORMANCE EXPECTATIONSDemonstrates the competencies as established on the Assessment and Evaluation Tool for this position.

WORK ENVIRONMENTPotential for exposure to the hazards and risk of the hospital environment, including exposure to infectious disease, hazardous substances, and potential injury. This position requires sitting, standing, walking, stooping and crouching a majority of the workday. Works with such equipment as computer terminal, fax machine, printer and copier.

REPORTING RELATIONSHIPThis position reports to the Volunteer Supervisor.

The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a

detailed description of all work requirements that may be inherent in the position.