Welcome to St. Joseph Mercy Ann Arbor and Livingston Volunteer Services.

NICU FAB

St. Joseph Mercy Ann Arbor develpoed the NICU Family Advisory Board to provide an extra level of support to parents and families of critically ill babies being cared for in the NICU. If you were a parent of a NICU baby and your baby is six months or older and are interested in becoming a member of FAB, please fill out the application below.
Please select the area you are applying for
Personal Information
Application date
First Name
Last Name
Address
City
State
Mobile
Zip/postal
DOB
Gender
E-mail
Emergency Contact
Phone Number
Relationship name
Employment
From
To
Mo/Yr.
Mo/Yr.
Position and Duties
Name of Company
City, State
Name of Company
Mo/Yr.
Mo/Yr.
Position and Duties
City, State
Briefly descibe your child's stay at St. Joseph Mercy Ann Arbor's NICU
What are some ways you see yourself helping? (select all that apply)
Parent- to- Parent
Educate & Create
NICU Annual Reuinon
Pizza Night
Fundraising
Why are you interested in being involved in the Family Adivsory Board?
Have you ever been convicted of anything other than a minor traffic citation, or are there felony charges pending against you?
Yes
No
If yes, please list dates, places, charges and dispostion of all convictions:
Is there anything not covered in this application that you would like to add?
Believing that Saint Joseph Mercy Health System (SJMHS) has a need for my services as a volunteer, I agree:
1. I voluntary offer my services with a clear understanding there will be no momentary compensations and that volunteering does not lead to employment.
2. To hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, families, physicians, or personal. I agree that I will not seek confidential information in regard to a patient or SJMHS personal.
3. That I will commit to the minimum requirements for the program I am participating in. I will adhere to the agreed upon schedule which would involve notifying areas in case of absences.
4. That if I accept a volunteer position, I will have a duty to be familiar with SJMHS' rules, standards, and policies as they now exist or as they may be modified, added to, or abolished in the future. I have reviewed and agree to comply with these rules, standards, and policies.
5. To wear the hospital ID at all times while volunteering for SJMHS and to return ID badge when I am no longer an SJMHS volunteer.
6. To give a minimum of two weeks notice to the NICU Family Advisory Board when I will be terminating my volunteer service.
I certify that the answers given by me to the foregoing questions are true and without omissions. Misrepresentation of facts constitutes separation from Volunteer Services. I agree to abide by all Saint Joseph Mercy Health System rules and regulations. It is further understood that the Volunteer Services Department is not obligated to provide a placement, nor am I obligated to accept the position offered.
Applicant Signature:
Date: