COLLEGE STUDENT Volunteer Application

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1 COLLEGE STUDENT Volunteer Application Please print clearly. Incomplete applications cannot be considered. TODAY S DATE: / / MALE FEMALE Name: Local Address: LAST FIRST MIDDLE NICKNAME STREET City STATE ZIP CODE Permanent Address: STREET City STATE ZIP CODE Phone: ( ) HOME ( ) CELL DRIVER LICENSE # STATE DATE OF BIRTH: / / NAME OF SCHOOL: YEAR: 1 ST 2 ND 3 RD 4 TH 5 TH MAJOR: GRADE POINT AVERAGE(GPA) Are you interested in pursuing a career in the medial field? YES NO What is your field of interest? Please list any foreign languages your speak: List any friends or relative employed by FHT: NAME RELATIONSHIP FHT DEPT DEPT PHONE# How did you hear about our program? Do you have any prior volunteer experience? YES NO If yes, how long? Where: Contact Name: Phone: ( ) 1 of 5

2 On which campus do you prefer to volunteer? CARROLLWOOD ON DALE MABRY HIGHWAY LTAC (LONG TERM ACUTE CARE CONNERTON) MEDICAL CENTER ON FLETCHER AVENUE PEPIN HEART INSTITUTE (ON FLETCHER CAMPUS) WOMEN S CENTER (ON FLETCHER CAMPUS) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY CHECK THE TIMES THAT YOU PREFER TO WORK: 6:00-10:00am 8:00-12:00pm 12:00-4:00pm 4:00-8:00pm Have you ever pled guilty, pled no contest or been convicted of any Felony or Misdemeanor other than parking tickets? YES NO If yes, please explain: Why did you decide to become a volunteer? Please list any physical restrictions that would limit your ability to perform volunteer duties: 2 of 5

3 All Volunteers are required to have a TUBERCULOSIS SKIN TEST (PPD) before starting volunteer duty. The test can be administered by your physician or by FLORIDA HOSPITAL EMPLOYEE HEALTH at no charge to you. Please check one of the following statements: I HAD A TB TEST WITHIN THE LAST YEAR, ENCLOSED IS A REPORT OF FINDINGS SIGNED BY A PHYSICIAN OTHER HEALTH PROFESSIONAL. I WAS TREATED FOR EXPOSURE TO TUBERCULOSIS OR HAD A POSITIVE TB TEST ON / / (date tested positive). Note: Attach a copy of the chest X-ray (within the past 5 years) to this form and send a copy to Employee Health. APPLICANT STATEMENT OF UNDERSTANDING: I certify that all of the information provided on this application is true, correct and complete. If I provide false, misleading or incomplete information, I will disqualify myself, regardless of the date of discovery. I understand that I may be dismissed from my duties for willful wrongdoing, performing duties outside of my service guidelines, poor attendance, poor attitude or non-adherence to the rules and regulations required by Volunteer Services and Florida Hospital Tampa. I understand all FHT campuses are tobacco free facilities and I agree to comply with this policy. I agree to initial TB testing before start of service and will be responsible for getting the required ANNUAL test thereafter. I agree to call my immediate supervisor and the Volunteer Coordinator if I have scheduling changes, if I cannot report for duty or if I am going to be absent for an extended period of time. I agree to abide by all policies and procedures set forth by FHT and Volunteer Services Department. Applicant Signiture: Date: / / 3 of 5

4 EMERGENCY MEDICAL INFORMATION PHYSICIAN S NAME: PHONE: ( ) PLEASE LIST TWO EMERGENCY CONTACTS: 1. ( ) ( ) NAME RELATIONSHIP WORK # HOME OR CELL # 2. ( ) ( ) NAME RELATIONSHIP WORK # HOME OR CELL # PLEASE CHECK ONE OF THE FOLLOWING STATEMENTS: I GIVE PERMISSION FOR IMMEDIATE EMERGENCY MEDICAL TREATMENT AT FHT. I DO NOT GIVE PERMISSION FOR EMERGENCY MEDICAL TREATMENT UNTIL AUTHORIZED BY AT LEAST ONE CONTACT PERSON. Applicant Signature: Date: / / 4 of 5

5 ADVISOR RECOMMENDATION Volunteer at Florida Hospital Tampa Volunteer Services, 2 ND Floor, Fletcher Campus (813) FAX (813) DATE: / / STUDENT NAME: Phone: ( ) ADVISOR NAME: Phone: ( ) POSITION/TITLE: COLLEGE NAME: ADVISOR: Please describe or explain why you are recommending this student to the Volunteer Program at the Florida Hospital Tampa. Advisor Signature: Date: Advisor Name: Telephone #: address: 5 of 5

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