COLLEGE VOLUNTEER APPLICATION

Transcription

1 COLLEGE VOLUNTEER APPLICATION Volunteer Services Telephone Number (813) TODAY S DATE: / / MALE FEMALE NAME: LAST FIRST MIDDLE NICKNAME ADDRESS: STREET City STATE ZIP CODE PERMANENT ADDRESS PHONE: ( ) ( ) HOME CELL DRIVER LICENSE # ST SOCIAL SECURITY #: / / DATE OF BIRTH: / / NAME OF SCHOOL: YEAR: 1 ST 2 ND 3 RD 4 TH 5 TH MAJOR: GRADE POINT AVERAGE(GPA) ARE YOU PURSUING A CAREER IN THE MEDICAL FIELD? YES NO WHAT IS YOUR FIELD OF INTEREST? PLEASE LIST ANY FOREIGN LANGUAGES YOU SPEAK: LIST ANY FRIENDS OR RELATIVES EMPLOYED BY FHT: NAME RELATIONSHIP FHT DEPT DEPT PHONE# HOW DID YOU HEAR ABOUT OUR PROGRAM? DO YOU HAVE PRIOR VOLUNTEER EXPERIENCE? YES NO IF YES, HOW LONG? WHERE: CONTACT NAME: PHONE: ( ) 1 of 6

2 Which campus do you prefer to volunteer? MEDICAL CENTER ON FLETCHER AVENUE CARROLLWOOD ON DALE MABRY HIGHWAY PEPIN HEART INSTITUTE (ON FLETCHER CAMPUS) WOMEN S HEALTH PAVILION (ON FLETCHER CAMPUS) LTAC (LONG TERM ACUTE CARE CONNERTON) 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 MISDEMANOR 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 6

3 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. 3 of 6

4 Tuberculosis Testing All volunteers are required to have two(2) tuberculosis skin tests before starting volunteer duty. This test may be administered by your physician or by: Please check one of the following statements: Florida Hospital Employee Health Department Location: 1 st Floor of the Main Hospital HOURS: Monday-Friday, 7:00a.m.-3:15p.m. Picture ID is required. I have had a TB test within the last year. Enclosed is documentation from the test. I was treated for exposure to tuberculosis or have 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 Services Department 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: / / 4 of 6

5 Volunteer Statement of Confidentiality I,, understand the basic principles of confidentiality of patient/hospital information and will follow these policies. I have read the Hospital Statement of Confidentiality below and understand this policy. POLICY: It is the policy of Florida Hospital Tampa to permit access by certain employees to certain privileged and/or sensitive information in order to effectively discharge their responsibilities. Such information may be contained in written, verbal or electronic media forms and includes: Information relevant to hospital operations and activities, whether actual or planned. Personal data related to past, present or prospective employees. Patient medical, billing and demographic information. User access codes for computers, doors, photocopiers, long distance calling, etc. Financial and budget information. Other information considered sensitive in nature. It is the policy of Florida Hospital Tampa that all volunteers are to be made cognizant and understand their responsibility for maintaining the confidentiality of such information. Confidential or sensitive information is to be held in strict confidence and is not to be discussed with or disclosed to anyone, except as required to properly discharge job responsibilities. Unauthorized disclosure of confidential or sensitive hospital information by a volunteer may result in dismissal from the volunteer department. VOLUNTEER SIGNATURE DATE / / STAFF SIGNATURE DATE / / 5 of 6

6 FOR OFFICE USE ONLY: Date submitted: / / Submitted by: Authorization # Date complete: / / VOLUNTEER SERVICES CONSUMER REPORT AUTHORIZATION I hereby authorize Florida Hospital Tampa and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or investigation consumer report to be generated for volunteer purposes. If selected this authorization will remain on file and shall serve as an ongoing authorization for Florida Hospital Tampa to procure consumer reports/investigative consumer reports at any time during my volunteer period. I understand that the scope of the consumer report/investigative consumer report may include but is not limited to the following areas: Verification of social security number, current and previous residences, employment history including all personnel fields, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state, count jurisdictions, birth records, motor vehicle records to include traffic citations and registration, and any other public records. I further authorize any individual, company, firm, corporation or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me to Florida Hospital Tampa or its agents. I further authorize the complete release of an records or data pertaining to me which the individual, company, firm, corporation, or public agency may have to, to include information or date received from other sources. I hereby release Florida Hospital Tampa, the Social Security Administration, its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release. I may be contacted as indicated below: Print name: First Middle Last Maiden Former name(s) and date(s) used: Current address: How long? Street Apt # City State Zip Phone: ( ) Social Security number: / / DOB: / / Signature: Date: / / 6 of 6

7 Employee Health Services VOLUNTEER REGISTRATION INFORMATION SHEET *Please take this to Employee Health when you receive your first TB test.* FACILITY: Florida Hospital Tampa Florida Hospital Carrollwood Long Term Acute Care PLEASE SELECT ONE: Adult Volunteer Student Volunteer Teen Volunteer PLEASE PRINT Date: Patient: Last Name First Name MI Home Address: City: State: Zip: Social Security #: DOB: Gender : Phone #: FLORIDA HOSPITAL TAMPA EMPLOYEE HEALTH Main Campus: 3100 E. Fletcher Ave. Tampa FL, (813) (813) Fax Carrollwood Campus: 7171 N. Dale Mabry Hwy. Suite # 403 Tampa Fl, (813) Ext (813) Fax