Teen Advisory Board(s) Application

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Thank you for your interest in and improving the quality, safety, and experience of care at Children's Mercy.

The health and safety of our patients and their families is paramount, so you will be required to complete a health form and obtain any necessary vaccinations, and a background screening. We hope you will consider joining this meaningful program by completing the Teen Advisory (TAB) application below. Information shared will be kept strictly confidential. Please create a New User account to apply by completing the User ID Field and Password Field below. All items with ( * ) indicate a required field.

If you are filling out this application on a mobile device, please make sure your screen orientation is unlocked and turn your phone to the side (landscape mode) to complete the application.

To Begin- create a user ID and password. You will use this user ID and password for additional steps in the onboarding process .

New User Details

User ID

User ID (verify)

Password

Password (verify)

Current date

Select the patient/teen advisory board(s) you are interested in applying for

Personal Information

* Please enter your legal first name (as it is written on your social security card)

* Please enter your legal middle name (as it is written on your social security card) If you do not have a legal middle name, enter n/a

* Please enter your legal last name (as it is written on your social security card)

Do you have a preferred first name that is different than your legal name?

Do you have a preferred middle name that is different from your legal name?

Do you have a preferred last name that is different than or a shortened version of your legal last name

* Date of Birth (Please enter as MM/DD/YYYY)

* Please enter your full 9 digit social security number without dashes (555555555). This is required to complete background screenings.

Gender

Ethnicity

Do you speak any additional languages besides English? If so, please click the box in the scroll bar to drag the box up and down to select your language(s). (The mouse scroll wheel tends to not scroll down):  

Communication Methods

* What is your cell phone number? Please add area code

Phone (Home)

* Please enter a personal e-mail address that you check often. All communication will be sent here.

Do you have a secondary email address that you would like for us to have on file to cc all email communication to? (such as a parent's email or school email)

Primary Home Address

* Line 1

Line 2

* City

State

* Zip Code: Please enter this as your zip code + 4 digits. You can find this on most of the mail you recieve. (Example: 64108-2420)

County

Parent/Legal Guardian Contact Information

The parent/guardian must be able to legally sign consents for you as well as serve as your emergency contact

* Emergency Contact First Name

* Emergency Contact Last Name

* What is your relation to your emergency contact? (i.e. mother, father, legal guardian)

* Parent/Guardian/Emergency Contact's E-mail Address (a consent that they will need to sign be sent to them here)

* Parent/Guardian/Emergency Contact Phone (Cell)

Emergency Contact Phone (Home)

Parent/Guardian/Emergency Contact Phone (Work)

Education

Are you currently enrolled in school?

If yes, what is the name of your school

Volunteer Affiliation(s)

CMH Volunteer Affiliation

Do you volunteer at any other organizations?

Other Outside Volunteer Location I serve

Your Experience at Children's Mercy

The information you enter into this form will be held in the strictest of confidence and will not be used or disseminated for any purpose other than as a tool to determine membership eligibility.

* Please briefly describe your experience with Children's Mercy.  

* Why are you interested in becoming more involved at Children's Mercy?

* Please share any improvements or ideas you would want to bring to Children's Mercy.

* Please list at least one clinic and/or provider who has cared for you that we may contact as a reference.

Consent and Acknowledgement Section
For adult volunteers (18+), please review, acknowledge each item below and sign this consent page.
For minor volunteers and adult volunteers with a guardian; your parent/legal guardian is required to review, acknowledge and sign their consent in order to participate in the volunteer program. This will be sent to them seperately via the email address listed in the emergency contact section of this application.

Are you legally able to sign your own consents?

* I understand that all forthcoming items must be consented to as the volunteer. I am a minor, an additional waiver/consent will need to be completed by the parent/gaurdian that I entered above.

* I understand that this application does not guarantee volunteer placement at Children's Mercy.

* I understand that I am applying for a volunteer position to willingly donate my time to specific tasks for public service and that the duration of the volunteer role is temporary without receipt of compensation (this is an unpaid role)

* I understand that this volunteer program requires a commitment for at least 6 consecutive months and the volunteer assignment will primarily be completed from home/online.

* I understand that I will be receiving e-mail communication from both the Volunteer Services Department as well as the Patient Family Engagement Team leader for my program. These emails often share critical volunteer updates such as required compliance items, orientation/training needs, scheduling/program updates, inclement weather, etc. Children's Mercy expects volunteers to review the information provided in these emails and respond if requested.

* I give permission to Children's Mercy to run a background check upon the initial enrollment in the volunteer program or once I turn 18 (whichever comes sooner); I also give permission to Children's Mercy to run reoccurring background checks as part of their standard practice.

* I agree for Children's Mercy to complete Missouri and Kansas Family Care Safety Registry Checks (FCSR) upon the initial enrollment in the volunteer program or once I turn 18 (whichever comes sooner);

* I agree to complete all initial and ongoing trainings that are required for this volunteer role.

* I understand that if I choose to participate in an onsite Volunteer Activity, I will be provided with a copy of the volunteer visitor guide which will outline Children's Mercy's health requirements and required immunizations. I understand that I will have to meet these requirements in order to participate in these types of Volunteer Activities.

* If I arrive at the Volunteer Activity with symptoms of being sick (e.g., a runny nose, cough, upset stomach), I understand and agree that I will not be able to participate in the Volunteer Activity and will be asked to leave or be picked up by my guardian. Should there be a lapse in time before I am able to leave the property due to needing a ride, I understand and agree that Children's Mercy staff will remove me from the Volunteer Activity to be placed in an alternate area of Children's Mercy until I can leave the property.

* I give consent to recieve emergency medical treatment if I/they become ill or injured while volunteering at Children's Mercy.

* I give my permission for Children's Mercy to take photographs of me. I understand the hospital staff will not contact me when photographs are chosen for use in any brochure or publication.

* I understand that my requirements could change at any time due to the ever changing nature of healthcare.

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Applicant Signature

* Signature Date

General Volunteer Questions
volunteer@cmh.edu
(816) 302-1020

Groups, Donations, & Junior Champions
donategoods@cmh.edu
(816) 302-1020

Parent Advisory Councils & POPS Mentors

pfa@cmh.edu

(816) 302-3800

Teen Advisory Councils

awoelk@cmh.edu

(816) 234-3702

Volunteering with a Disability

klgomer@cmh.edu

(816)-234-3000 ext. 51869

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