Parents as Partners Volunteer Application

(This application is only for Cook Children's parents who want to volunteer in our Parents as Partners programs.)

Parents as Partners Volunteer Information:

Thank you for your interest in getting involved as a parent to parent volunteer. Parents are a tremendously important part of the Cook Children's team. Your participation will be very valuable to us and to other parents.

Your next steps:

You will be required to attend New Volunteer Orientation (3 hours) which is held monthly in the evenings or on a Saturday morning. All training supplies are provided at no charge.
COVID vaccination is no longer required but is highly recommended. TDaP vaccination is required.
A record of varicella (chicken pox) immunity must also be provided to Cook Children's before you attend New Volunteer Orientation. This can be one of the following:
- Proof of having received the two varicella vaccinations from your medical/immunization record.
- Proof of a positive blood titer (blood work) showing that you are immune to varicella from Cook Children's Occupational Health Dept. If your blood work shows you are not immune (negative), Cook Children's will provide the varicella vaccinations to you at no charge.
  - A shingles vaccination is not proof of having had chicken pox as anyone can get one whether they have had chicken pox or not.
Cook Children's requires volunteers to complete an initial Tuberculosis (TB)skin test and an annual flu vaccination. This is provided at no charge to you.

If you have any questions about the forms or requirements, please call the volunteer office at 682-885-4598.

Thank you!

Marian DeMott
Volunteer Program Coordinator

Parents as Partners Programs:

* First name

Middle name

* Last Name

Title

Nickname

* Street Address

Line 2

* City

* State

* Zip/postal

E-mail

* Phone (Home)

* Phone (Mobile)

Personal Information

* DOB

Ethnicity

Have you ever worked for Cook Children's?

Current Grade or Education Completed

School or University

Career/Career Interest(s)

Medical Alert

Allergy Alert

T-Shirt Size

Recognition Preferences

About You

Why have you chosen to give back to Cook Children's by volunteering for the Parents as Partners program?

How did you learn about this volunteer opportunity?

About Your Children Who Are Cook Children's Patients

Child First Name

Child Last Name

Gender

Date of Birth

Diagnoses and Medical History

Please specify primary diagnoses

Physician(s)

Clinic Services

Medical Procedures

Treatment and equipment

Common issues

Comments

Child First Name

Child Last Name

Gender

Date of Birth

Angel Date

Diagnoses and Medical History

Please specify primary diagnoses

Physician(s)

Clinic Services

Medical Procedures

Treatment and equipment

Common issues

Comments

Child First Name

Child Last Name

Gender

Date of Birth

Angel Date

Diagnoses and Medical History

Please specify primary diagnoses

Physician(s)

Clinic Services

Medical Procedures

Treatment and equipment

Common issues

Comments

Child First Name

Child Last Name

Gender

Date of Birth

Angel Date

Diagnoses and Medical History

Please specify primary diagnoses

Physician(s)

Clinic Services

Medical Procedures

Treatment and equipment

Common issues

Comments

Child First Name

Child Last Name

Gender

Date of Birth

Angel Date

Diagnoses and Medical History

Please specify primary diagnoses

Physician(s)

Clinic Services

Medical Procedures

Treatment and equipment

Common issues

Comments

Background Check

You will be asked to sign an authorization form allowing your background check to be completed. Applicants must have a clear record (no arrests, convictions, nolo contendere pleas, deferred adjudications, or any other criminal entries). Per Cook Children's policy, you will be declined as a volunteer if there are any blemishes on your background check.

Emergency Contacts

* Contact name

Phone (Home)

* Phone (Mobile)

Relationship name

CONFIDENTIALITY AGREEMENT & PHOTO RELEASE

I understand and agree that in the performance of my duties as a volunteer of Cook Children s Health Care System I must hold in strictest confidence any observations I may make or information I may hear regarding patients, patient families or staff.

I verify that all of the information provided by me on thisapplication is true, correct and complete. I attest that I have never been arrested or charged with any crime and grant Cook Children's permission to verify this information in arriving at a decision.

I understand that false or misleading statements or the omission of any information necessary to make this application complete will result in rejection of my application or termination of my service.

Additionally, Cook Children's has my consent to photograph, videotape, or audiotape me performing my volunteer duties. I understand that these may be used toward the advancement of public education, the promotion of Cook Children's, and/or any other legitimate purpose.

I understand that upon my successful completion of the volunteer placement processes required at Cook Children's, I will become a volunteer. As a volunteer, I acknowledge that I will not receive compensation for services.

* I agree

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