Patient Family Engagement Application

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Thank you for your interest in improving the quality, safety, and experience of care at Children's Mercy. Applicants must be a current or former Children's Mercy patient, parent, or primary caregiver. To ensure the safety of our patients, families, staff and volunteers; Children's Mercy requires all volunteers to complete online education annually and undergo a background check every two years.

Please answer the following questions to the best of your ability. All items marked with (*) indicate a required field. Information shared in this application is on a secure server and will remain confidential.

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.

Please save your username and password - You will need to login with 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

* Volunteer Role You are 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)

Please add any credentials you have such as RN, MD, etc.

Do you have a preferred first name that is different than your legal name? (Please leave this line blank if you do not)

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

* Phone (Cell)

Phone (Home)

Phone (Work)

* Please enter a personal e-mail address that you check often. All communication will be sent here. If you are a CMH employee- you cannot enter your @cmh.edu email address

Do you have a secondary email account that you would like for us to have on file?

Primary Home Address

* Line 1

Line 2

* City

State

* Zip Code

Education

Are you currently enrolled in school?

Name of School

Employer

CMH Employee affiliation

* CMH position title

* CMH department

* CMH location/site

Please provide your current or previous Children's Mercy employee ID number if you know it

Are you currently employed?

Who is your employer?

Volunteer Affiliation(s)

Do you volunteer at any other organizations?

The other volunteer locations/organizations in which I serve are:

Emergency Contact Information

* Emergency contact first name

* Emergency contact last name

* What is your relation to your emergency contact? (i.e. spouse, mother, neighbor)

* Emergency Contact Phone (Cell)

Emergency Contact Phone (Home)

Emergency Contact Phone (Work)

Your Experience at Children's Mercy
The information you provide will be held in the strictest of confidence and will not be used or disseminated for any purpose other than as a tool to match a POPS mentor with requesting families and/or determine volunteer eligibility.

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

* Why are you interested in volunteering at Children's Mercy?

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

Please list other ways you are involved with or connected to Children's Mercy.

* Please list at least one clinic and/or provider who has cared for your child(ren) that we may contact as a reference.

Child(ren)'s Information
Please provide the name(s) and birthdate(s) of your child(ren) who are cared for at Children's Mercy.

The information that you provide will be held in the strictest of confidence and will not be used or disseminated for any purpose other than a tool to match a POPS mentor with requesting families and/or to determine volunteer eligibility.

If you are a current or former patient, please enter your information here.

* Child's First and Last Name

* Child's Date of Birth

Child's Gender

* Primary Diagnosis

Secondary Diagnosis

* Please share any additional medical information or experiences that are applicable and that you may be willing to share with another parent (ie. tracheostomy, feeding tube, pump, surgeries, equipment, community resources, social/emotional, other)

Do you have additional children in the home?

* Child #2's First and Last Name

* Child #2's Date of Birth

Child #2's Gender

* Child #2's Primary Diagnosis

Child #2's Secondary Diagnosis

Please share any additional medical information or experiences that are applicable and that you may be willing to share with another parent (ie. tracheostomy, feeding tube, pump, surgeries, equipment, community resources, social/emotional, other)

Child #3's First and Last Name

Child #3's Date of Birth

Child #3's Gender

Child #3's Primary Diagnosis

Child #3's Secondary Diagnosis

Please share any additional medical information or experiences that are applicable and that you may be willing to share with another parent (ie. tracheostomy, feeding tube, pump, surgeries, equipment, community resources, social/emotional, other)

Consent and Acknowledgement Section
For adult volunteers (18+), please review, acknowledge each item below and sign this consent page.

For adult volunteers with a parent/legal 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 you separately 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 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 application does not guarantee volunteer placement at Children's Mercy.

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

* I agree and give my permission to share my name, phone number, and email address to the families I am matched with as needed.

* I give permission to Children's Mercy to run a background check upon the initial enrollment in the volunteer program, 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 placement and prior to serving as a volunteer.

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

* I give permission for Children's Mercy to take photographs of me and/or my child as a volunteer; for badge and/or media related publications. I understand the hospital staff will not contact me when photographs are chosen for use in any brochures or publications.  

* 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.

* I agree to receive emergency medical care as needed if I become ill or injured while volunteering at Children's Mercy.  

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

Please add your signature to complete the application and sign off on your agreements to the statements above.

* Typed Name

[ clear ]
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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