Ambassador Application

Transcription

1 Ambassador Application Dear Applicant, Thank you for your interest in Dallas Medical Center s Ambassador Program! Your willingness to invest a few hours each week is greatly appreciated. I believe you will find serving as a DMC Ambassador at our hospital to be a rewarding and enjoyable experience. We have many opportunities in a variety of areas for you to consider: Patient Care assisting with patients, providing nourishments, helping with linens, assisting the desk, etc. Allied Health Services assisting staff in Physical Therapy, Laboratory or Pharmacy. Administrative data entry, filing, mailings, making copies, etc. As you can see, if you have a desire and a skill, we have a place for you. Please fill out the attached application and return to: Dallas Medical Center Attn: Lisa Shaw Nursing Administration 7 Medical Pkwy. Dallas, TX Once I have received your completed application and the background check (if over 18) is complete, I will call you to set up an appointment with the Employee Health Nurse to conduct the Health Screens (TB and Drug Screen). After the application process is complete, I will call to set up a convenient time to provide you with the required orientation. I look forward to working with you! Sincerely, Lisa Shaw Nursing Administration LShaw@primehealth.com

2 Guidelines for Ambassador Applicants The following guidelines are to inform you of the procedures for becoming an Ambassador at Dallas Medical Center. You must be at least 15 years of age. You must be able to serve a minimum of 4 hours per week or 20 hour commitment per month. TB (PPD) or Chest X-ray & Drug Screen Tests (All volunteer and employee applicants are required to have these tests. Please contact your family physician or Health Department for records of TB tests). DMC will perform Drug Screen Test and TB at no charge. If needed, I will schedule this through Human Resources after completion of forms and DMC test. DMC Ambassadors are required to follow the Code of Conduct, Ethics and Code of Confidentiality. Remember, you are a vital part of our hospital. Please adhere to our work schedule (we re depending on you). If conflicts arise, contact your department s supervisor. The Education Coordinator has the authority to dismiss any Ambassador for non-compliance of conduct and confidentiality. DMC Ambassadors wear blue pants and a white polo that they purchase All Ambassadors receive an identification badge, which is to be worn on your shirt at all times while on service. It is to be returned when you resign. An Orientation will be scheduled after the application process is completed. Your application will be processed after we receive the following: Ambassador Applicant Information form Confidentiality Statement Two Referrals Notarized Authorization for Medical Treatment (if applicant is under 18) Immunization Records Authorization and Consent for TB test (if applicant is under 18) Authorization and Consent for Drug Screen Test (if applicant is under 18) TB Report from Medical Facility or Physician and Drug Screen Test Report Background Check (if applicant is 18 and over) I have read and understand the Guidelines and wish to join the Ambassador Program at Dallas Medial Center. Signature of Ambassador Applicant: Date: Print Name:

3 Signature of Parent/Legal Guardian: Date: (If Applicant is under 18) Print Name: Ambassador Applicant Information Name: Phone: (Print) Last First Middle Address: Street/Apt. # City State Zip In case of Emergency Contact: Print Name Relationship Phone # School/College Attending: Date of Birth: Education or Special Training/ Abilities: Work Experience: Volunteer Experience with Non-profit or Charitable Organizations: Limitations related to health: Medical Reference: Physicians name, address and phone number Areas of interest in the hospital: Days/Time Available: Statement of Understanding: I will have a continuing responsibility to keep Dallas Medical Center (DMC) informed of any health situation which may affect my ability to perform my Volunteer assignments. Responsibilities and duties, including but not limited to unusual stress, physical injury impairment, back/muscle strain/sprain, any infectious disease, or any condition that may make me susceptible to infection. The above information is accurate to the best of my knowledge and ability. I understand that this will become a part of my medical record. DMC is an equal opportunity employer. No discrimination will be made with regard to race, color, religion, national origin, age, sex, veteran s status or physical disability. I understand I am providing service strictly on a voluntary basis and have no expectation for compensation. Your signature indicates approval for us to check references, perform a background check (if 18 yrs. And older) and contact your physician to determine if you are able to perform the duties of the Ambassador position you applied for in a reasonable and safe manner. I hereby release any individual or entity, including record custodians, from any and all liability for damages of any kind of nature which may at any time result to me on account of compliance or any attempt to comply, with the objective of this Statement.

4 Ambassador Signature Date Print Name Parent or Legal Guardian Signature Date Print Name Ambassador Confidentiality Agreement I understand the following: I am to perform tasks assigned to me. I must follow all rules and regulations of Dallas Medical Center (DMC) All information concerning DMC and its patients are strictly confidential. I hereby agree to maintain this confidentiality according to HIPAA regulations and will comply with them. Breaching confidential information will result in my removal from the Ambassador. Ambassador Signature Date Print Name Parent or Guardian Hold Harmless Statement for Student Ambassadors (Under 18 years of age) It is understood and agreed that I shall not bring, or cause to be brought, any action due to any personal injury or property damage that might result from my son/daughter s participation in any aspect of the Ambassador Program at Dallas Medical Center (DMC) I agree to accept full responsibility and to hold harmless DMC, it s employees, directors, officers, trustees, or agents from any and all claims and damages that may arise from my son/daughter s participation in the Ambassador Program.

5 Parent or Legal Guardian Signature Date Print Name DMC Ambassador Authorization for Medical Treatment (Under 18 years of age) I authorize the Dallas Medical Center, or designee, to act on my behalf in case my child is injured or becomes ill, when immediate medical or surgical care is needed, provided diligent efforts are made to notify me and obtain my preferences. If such efforts fail, I authorize medical action and give consent on my behalf. I will be responsible for payment of services rendered. Ambassador Name: Date: (Print) Last First Middle Date of Birth: In case of Emergency Contact: Phone: List any ongoing medical condition and/or medications: Immunizations current? Allergies: Family Physician Name: Phone #: Insurance Company: Policy #: Ph#: Statement of Notary Public Before me the undersigned authority on this day personally appeared:, known to be the person whose name is subscribed to the foregoing instrument, and acknowledges to me that he/she executed the same for the purposes and

6 considerations therein expressed and in the capacity therein stated. Given under my hand and seal of office this day of 20. Notary Public: County, Texas My Commission Expires: Witness: Witness: Signature of Student Volunteer Applicant: Print Name Parent/ Legal Guardian: Last First Middle Parent/Legal Guardian Signature: (You may arrange for utilizing our notary if requested) DMC Ambassador Authorization and Consent for TB Skin Test (If Applicant is under 18 yrs. of age) This serves as authorization to allow my child to receive a TB skin test to be administered by the Registered Employee Health Nurse at Dallas Medical Center. The purpose of the PPD (Purified Protein Derivative) intradermal skin test is to aid the detection of tuberculosis or the exposure of TB. This test will not be considered valid until the Ambassador Applicant has the skin test read within 48 to 72 hours. Date: Print Name of Ambassador Applicant: Last First Middle Signature of Ambassador Applicant:

7 Date of birth: SS # Print Name Parent/Legal Guardian: Last First Middle Parent /Legal Guardian Signature: Any questions or concerns, please call Lisa Shaw Nursing Administration at DMC Ambassador Authorization and Consent for Drug Screening Test (If Applicant is under 18 yrs. of age) This serves as authorization to allow Dallas Medical Center s Employee Health Nurse to collect a urine specimen for the purpose of drug testing for substances which may impair the Ambassador Applicant s ability to safely perform his/her job. We understand the results will be reviewed by the Employee Health Nurse and Education I will be required to sign lab consent forms, leave requested items outside the restroom and wash my hands and nails thoroughly prior to providing the specimen. My parent/ legal guardian signatures below indicate that we have read and understand this consent form and voluntarily agree to have the testing performed at no charge. Our signatures also indicate that we fully understand Dallas Medical Center s position on prohibited drug use. Date: Print Name of Ambassador Applicant:

8 Last First Middle Signature of Ambassador Applicant: Date of birth: SS # Print Name Parent/Legal Guardian: Last First Middle Parent /Legal Guardian Signature: Any questions or concerns, please call Lisa Shaw Nursing Administration at Referral for Ambassador Applicant is interested I serving as an Ambassador at Dallas Medical Center and has given your name as a reference. Our Ambassadors perform an important role in helping us provide compassionate and high quality medical care. Their work typically brings them in personal contact with our patients and families. We would appreciate your time in completing this reference form and returning it to: Nursing Administration Attn: Lisa Shaw Dallas Medical Center 7 Medical Pkwy. Dallas, TX How long have you known the Ambassador applicant?

9 Why do you recommend him/her for service as an Ambassador? Please comment on this person s: Dependability: Judgment: Desire to serve others in a medical environment: Please express any additional comments regarding this person s qualities: Relationship to Applicant: Phone Signature Print Name Date