Sparrow Banner Special Interest Volunteer Application
Please fill out all of the fields.
Attention: Please only fill out this application if you have been directed to.
Volunteer Contact Information
Emergency Information (Person to be notified in the event of an Emergency)
Special Interest you will be joining
If you are not applying to become a part of one of the groups on the list please be sure you are filling out the correct application. Contact the Volunteer Services office at (517) 364-3606, option 1 with questions.
Criminal Background Check
I hereby willingly consent to the completion of a background investigation and authorize Sparrow and/or its agents to request from any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, any records or information pertaining to me. I further authorize any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, to divulge any and all information, verbal or written, pertaining to me, including information or data received from other sources to Sparrow and/or its agents.

It is my understanding that any information obtained in the course of the background investigation will be held strictly confidential by Sparrow and its agents. Information gathered will be used only in connection with the volunteer placement process. I hereby authorize Sparrow and/or its designated agents and representatives to conduct a comprehensive review of my background, which may include information concerning my criminal, motor vehicle, and other history.

I understand this authorization automatically expires 90 days from the date executed below and that I have the right to revoke this authorization at any time, provided I do so in writing to Sparrow.
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 Drug Administration as a nicotine product. Nicotine patches and gum are also included.
This is your Confidentiality Agreement with Sparrow Health System. Please read in its entirety and sign at the bottom.

As a 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.

Volunteer Release and Waiver of Liability Form

This Release and Waiver of Liability (Release├») is entered into as of the ___ day of _________________, 20___ by 

_____________________________ (Volunteer) and Sparrow Health System, a Michigan nonprofit corporation (SHS),

 on behalf of itself and its affiliates and subsidiaries (collectively referred to as Sparrow).

WHEREAS: Volunteer desires to provide volunteer services for Sparrow and engage in activities related to serving as a 

volunteer (Services), and 

 

WHEREAS: Volunteer understands the duties expected of Volunteer and has read and understands the mission statement 

of Sparrow and its best practices procedures. Volunteer pledges to act and perform within these expectations, and

WHEREAS: Volunteer understands that the scope of Volunteer's relationship with Sparrow is limited to a volunteer 

position and that no compensation is expected in return for Services provided by Volunteer; that Sparrow will not provide 

any benefits traditionally associated with employment to Volunteer; and that Volunteer is responsible for his/her own 

insurance coverage in the event of personal injury or illness because of 

Volunteer Services to Sparrow, and 

 

WHEREAS: Volunteer understands and agrees to provide Sparrow with a release and waiver of liability as follows:

1. Waiver and Release: Volunteer, releases and forever discharges and holds harmless Sparrow and its directors, officers,

employees, agents, and volunteers, and its successors and assigns, from all liability, claims, and demands of whatever 

kind of nature, either in law or in equity, which arise or may hereafter arise from the Services Volunteer provides to 

Sparrow. Volunteer understands and acknowledges that Volunteer discharges Sparrow and its directors, officers, 

employees, agents, and volunteers, and its successors and assigns, from any liability or claim that Volunteer may have 

against Sparrow, with respect to bodily injury, personal injury, illness, death, or property damage that may result from the 

Services that Volunteer provides to Sparrow, or which occur while Volunteer is providing such Services.

2. Assistance and Insurance: Volunteer understands that Sparrow does not assume any responsibility for or obligation to

provide Volunteer with financial or other assistance, including but not limited to medical, health, or disability benefits or 

insurance. Volunteer expressly waives any such claim for compensation or liability on the part of Sparrow beyond what 

may be offered freely by Sparrow in the event of injury or medical expenses incurred by Volunteer.

3. Medical Treatment:Volunteer hereby releases and forever discharges Sparrow and its directors, officers, employees

and agents, and its successors and assigns, from any claim whatsoever which arises or may hereafter arise because any 

first-aid treatment or other medical services rendered in connection with an emergency during Volunteers tenure as a 

volunteer with Sparrow.

4. Assumption of Risk: Volunteer understands that the Services Volunteer provides to Sparrow may include activities that 

may be hazardous to Volunteer. Volunteer hereby expressly assumes risk of injury or harm from these activities and 

releases Sparrow and its directors, officers, employees, agents, and volunteers, and its successors and assigns, from all 

liability.

5. Media Release: Volunteer consents to and allows any use and reproduction by Sparrow of any audio, video and 

photographs (in any media format including but not limited to electronic or digital) (Media), taken of Volunteer (or any 

family member of Volunteer) during the time Volunteer is providing Services. Volunteer understands that Sparrow will 

own the Media and the right to use or reproduce such Media, as well as the right to edit them or prepare derivative works, 

for the purposes of promotion, advertising, and public relations. Volunteer hereby consents to Sparrows use of Volunteers 

name, likeness or voice, and agrees that such use will not result in any liability to these parties for payment to any person 

or organization, including Volunteer.

 

6. Other: Volunteer expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of 

the State of Michigan and that this Release shall be governed by and interpreted in accordance with the laws of the State 

of Michigan. Volunteer agrees that if any clause or provision of this Release is deemed invalid, the enforceability of the 

remaining provisions of this Release shall not be affected.

By signing below, Volunteer expresses Volunteers understanding and intent to enter into this Release and Waiver of 

Liability willingly and voluntarily.

 

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