Dear Prospective Volunteer

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 youdon'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 againstRubella and Rubeola, and Chickenpox immunity if you are volunteering in certain areas. If you have hada 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 Hospice and Palliative Care

ATTN: Maureen Hope

P. O. Box 1626

Pleasantville, NJ 08232

OR

you may fax to 609-407-2029, OR scan and e-mail to , OR

you may hand deliver the forms in an envelope marked to the attention of Maureen Hope, AtlantiCare Hospice,

Airport Commerce Center, Building 300, Suite 210, Egg Harbor Township, NJ 08234.

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 screeningif no documentation of 2 MMR vaccines

·  Varicella screening if no history of chickenpox disease ordocumentation ofvaccination

·  T-dap vaccination may be required

·  Drug Screening

·  **PLEASE NOTE - If the test results indicate you are not immune toRubella 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 Hope

Volunteer Supervisor

Volunteer Services Department – phone: 609-407-2030, fax: 609-407-2029, e-mail:

VOLUNTEER APPLICATION

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

Instructions: Please complete ALL parts on this application. Incomplete applications cannot be processed. Please call the Volunteer Office at 609-407-2030 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? q No q Yes

If yes, when and which department? ______

Do you have any relatives who are employed or volunteer at AtlantiCare? q No q 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 in

Egg 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?

q Health Park q Airport Commerce q Atlantic City q Pomona q Any location

How would you like to volunteer with AtlantiCare?

(Volunteer opportunities are based on department needs. Please check all areas of interest.)

q Interacting with patients (e.g. visiting patient rooms, sitting with patients to offer companionship, hospitality cart)

q H.E.L.P. – Hospital Elder Life Program – working with hospitalized seniors

q Interacting with the public (e.g. information desk, hospital guide, registration, dietary, accompanying musicians

throughout the hospital)

q Heart Heroes – participate in fund raising activities to place automated external defibrillators in our community

through a matching funds program

q Logistics (e.g. restocking, rotating inventory, delivering supplies)

q Clerical help (e.g. filing, computer data entry, assembling information packets, phone support, laminating, mailings)

q Gift Shop sales (e.g. pricing of items, stocking shelves, sales, cashier)

q Creative Arts and Healing Program (e.g. musicians, licensed pet therapy, etc. to visit patients or perform in lobbies)

q Auxiliary (fundraising/community representatives of the hospital, $10 annual dues)

q Bumper “T” Caring Clowns (Interested volunteers complete a comprehensive clown training course offered by

Bumper “T” Caring Clowns on the art of gentle humor. They use therapeutic clowning as a powerful tool to promote

the healing process. From the moment they enter a hospital, the Caring Clowns consider themselves a positive,

healing force. They pride themselves on being masters in the art of “reading” a room, listening, and using gentle

humor to make true connections with the people who need them. www.bumpertcaringclowns.org for more information.

q 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 of the application 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.

q Other interests for volunteering? Please explain:______

______

______

Volunteers are usually scheduled for four hour shifts, at least once a week.

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

explain:______

______

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

DO YOU SPEAK ANOTHER LANGUAGE? q No q 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?

q No q 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… q Athletic/Fitness q Crafts q Filing

q Enjoys interacting with people q Good listener q Writing q Proofreading/Editing q Procurement of donations

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

q Ordained Minister-What denomination?______

q Musician - What instrument(s)/talent:______

q Computer Literate q no q yes q 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):

o Some or no High School o College, please specify degree: ______

o High School o Graduate, please specify degree: ______

o 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 QUESTIONNAIRE

The 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 INTERESTED

IN 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? o Yes o No

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

______

2. Have you lost anyone close to you in your lifetime? o Yes o 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?

o Direct Patient Care o Bereavement Volunteer o Office Help o Computer Data Entry o Fundraising

5.  How far are you willing to travel to participate as a volunteer? ______miles ______minutes

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

7.  Please list any allergies:______

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.