Adopt-A-Floor Membership

Thank you for your interest in volunteering with us!

Please complete the form below to begin the application process. If the application is approved, a member of our team will follow up with your application status. Requests must be made at least one month in advance to prepare for your donation. Please complete this form for each donation visitation. Masks are required.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Requested site

Are you a returning Adopt-A-Floor Group?

Group name

Event Coordinator First Name

Event Coordinator Family (Last) Name

Phone (Mobile)

Phone (Business)

Group Director Name

Group Director E-mail

Group Director Phone (Mobile)

Group Director Phone (Business)

Group Address

Address Line 2

City

State

Zip/postal

* Number of Volunteers

Is your agency affiliated with any other volunteer organization?

If so, please give name(s):

Name of other agency director(s):

Length of affiliation(s):

* What department/floor would you like to adopt?

* Why do you choose to join the Adopt-A -Floor Volunteer Program? Specify group activity and preferred age group.

* Date'(s) of visit'(s) requested:

* Requested Time

What will you be donating?

Donation Date 1

Donation Date 2

Recurring Donation

Are you or have you ever been an employee at JHS/JMH?

We thank you for keeping our patients' needs in mind, please note the regulations below:

Membership application must be completed. Volunteer Services will review and send confirmation of visit if approved.
Events must be planned and approved for appropriateness one month prior to requested date of visit.
Groups may schedule AAF visit at discretion of Department Manager.
We will accommodate events on a "first come first serve basis" according to appropriateness.
Groups must arrive within 30 minutes of scheduled visit or the event may have to be rescheduled.
Event coordinator is responsible for relaying JHS guidelines to all other visiting members.
Participants must be in good health, free of illness (i.e. flu/cold symptoms) on the day of their scheduled visit.
Due to HIPAA regulations, photographs are not permitted unless prearranged and approved by Department and/ or the JHS Communications and Outreach Department.
Religious or politically focused gifts/activities or interactions with patients and their families are not permitted.
We discourage food and drinks due to patients' dietetic regimens and no latex balloons..
Each group will be limited to five (5) participants per event. No one under the age of 15 permitted to participate.
Garage parking is complimentary for up to 2 hours per visit.

I agree to abide by the policy/procedure set forth by Jackson Health System and the Volunteer Resources Department. I/we will agree to keep all patient information confidential. I/we understand that volunteers are not paid for volunteer services rendered. I understand that failure to abide by the above mentioned guidelines are grounds for immediate dismissal. Masks are required.*

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