Adult Volunteer Application - Open Schedule Job

PLACEMENT CONFIRMATION

You are applying for: Emergency Center Volunteer

VOLUNTEER INFORMATION

Name prefix

* First Name

Middle Initial

* Last Name

Do you have a preferred first name or nickname? If so, we will use this to address you, and on your identification badge.

* Date of Birth (format 00/00/0000)

Gender

* Home Address

* City

* State

* Zip Code

* Primary Phone

* E-mail Address

Drivers License

State Issued

To comply with CMS regulations, we must ask for your Social Security Number. If you do not have one, enter 000-00-0000 and check the box that states, "I do not have a Social Security Number." You are not required to be a U.S. citizen to volunteer at Harris Health.

* SSN

I do not have a Social Security Number.

Shirt Size

Marital Status

Language

Additional languages

Ethnicity

Volunteer Referral Source

Group Code

Length able to commit

EMERGENCY CONTACT INFORMATION

* Primary Contact Name (First,Last)

* Relationship

* Primary Phone

* E-mail

Home Address

City

State

Zip Code

PHOTO RELEASE:

As a Harris Health volunteer, I realize that my image may be taken at celebrations and other media events. I give my permission to Harris Health, Director of Volunteer Services, and the Administrative Director of Corporate Communications to use my image in any appropriate and related materials that will promote or otherwise publicize the Volunteer Department or Harris Health.

BACKGROUND CHECK AUTHORIZATION:

I authorize Harris Health to conduct any and all inquiries necessary to determine my acceptability as a volunteer, including a thorough background check. I understand that this background check may include verification of personal and/or employment references, military information or police record inquiries.

* I am 18 years of age or older.

Have you ever been convicted of or been on deferred adjudication for, or are you now either awaiting trial for or on deferred adjudication for a felony or misdemeanor?

List and explain convictions, if any:

CONFIDENTIALITY AGREEMENT:

I agree to use confidential or proprietary information only as needed to perform my volunteer duties. This means I will not access confidential or proprietary information without legitimate need/permission, nor in any way divulge, copy, release, sell, lend, revise, alter, or destroy any confidential or proprietary information belonging to Harris Health.  I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality.

VOLUNTEER AGREEMENTS:

If accepted as a Harris Health Volunteer, I agree to the following:

1. Understand that it is a crime to solicit business for attorneys and/or insurance companies.

2. Authorize Harris Health System to provide me with a TB test as part of my volunteer service. Should I test positive, I understand that I must provide the Volunteer Services Department with a letter from my physician stating that my TB is inactive before continuing my volunteer duties.

3. Am donating my services to Harris Health without expectation of compensation and am not to solicit employment while performing my volunteer duties.

4. Understand that the Volunteer Services Department does not assign volunteers to areas of professional or medical conflicts of interest.

5. Will not sell or attempt to sell any goods or services, solicit monetary or in-kind contributions, or collect/distribute petition signatures on Harris Health premises.

6. Understand that I must never attempt to assess or diagnose any patients, nor shall I attempt to perform any medical procedures (i.e. draw blood, insert an IV and any other procedure that requires a medical license) on patients.

7. Understand that, I will be evaluated by the Volunteer Services Department, as well as the department in which I have been placed. I also will be given the opportunity to evaluate the department and the volunteer duties that I have been assigned.

8. Understand that the Volunteer Services Department reserves that right to terminate my volunteer status as a result of: Failure to comply with Harris Health and departmental policies, rules and regulations; Unsatisfactory attitude, work or appearance/attire; Habitual tardiness and/or absences; and/or any behavior deemed unacceptable by any Harris Health facility, department supervisor and/or the Volunteer Services Department.

9. I understand that, I am responsible for returning my badge and uniform to the Volunteer Services Department after completing my volunteer assignment.

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Signature Field