3100 East Fletcher Ave. Tampa, FL fax:

Transcription

1 College Student 3100 East Fletcher Ave. Tampa, FL Volunteer Application Volunteer opportunities are offered without regard to religion, creed, race, national origin, age or gender. PLEASE PRINT CLEARLY. Date: / / Male Female Date of Birth / / Last Name First Name Middle Name Nickname Local Address: Street City State Zip Permanent Address: Street City State Zip ( ) ( ) address Home Phone Cell Phone If you have used another name in the last 5 (five) years, please identify name(s) and date(s): Year: 1st 2nd 3rd 4th 5th Name of School Major/Minor: Grade Point Average(GPA) Pursuing a career in the medial field? Yes No Field of interest? List all languages you speak: List Friends or Relatives employed by Florida Hospital: Name Relationship Department Phone Please list any physical restrictions that might limit your ability to perform volunteer duties: Volunteer Experience Yes No Organization & Position: Why do you want to become a Volunteer? I am interested in working at the following locations (check all that apply): Florida Hospital Tampa (FHT), Fletcher Ave. Pepin Heart Hospital (next to FHT) Women s Center (next to FHT) Florida Hospital Carrollwood (Dale Mabry Hwy) Florida Hospital Long Term Acute Care Facility (LTAC Connerton) Preferred work days/hours: DAY 1 st Choice 2 nd Choice 3 rd Choice 4 th Choice MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY 1 of 5

2 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: 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. I understand all Florida Hospital 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 the Volunteer Office, or my immediate supervisor, if I have scheduling changes, cannot report for duty or if I am going to be absent for any period of time. I agree to attend all required annual in-service events and to abide by all policies and procedures set forth by Florida Hospital and the Office of Volunteer Services. / / Printed Name Signature Date All Volunteers are required to have a TUBERCULOSIS SKIN TEST (PPD) before starting. 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, attaches is the signed report finding. I was treated for exposure to tuberculosis or had a positive TB Test on / /. Attached is a copy of the chest X-ray (within the past 5 years) to this form and send a copy to Employee Health. EMERGENCY MEDICAL INFORMATION Physician s name: Phone ( ) Emergency Contact: 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 Florida Hospital. I do not give permission for emergency medical treatment until authorized by at least one contact person. 2 of 5

3 RECOMMENDATION STATEMENT Florida Hospital Tampa, Office of Volunteer Services, 2 nd Floor DATE: / / Student Last Name First Name Middle Name Nickname ( ) - Name of Recommender address Phone Position/Title: Organization: Briefly describe/explain why you are recommending this student to the Volunteer Program at the Florida Hospital Tampa. Signature: 3 of 5

4 FOR OFFICE USE ONLY: Date submitted: / / Submitted by: Date complete: / / Entered by: Authorization #: VOLUNTEER SERVICES CONSUMER REPORT AUTHORIZATION Sterling Background Screening 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 any 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: First Name Middle Last Maiden Former name(s) and date(s) used: Current address: How long? Street Apt # City State Zip Previous address: Dates: Street Apt # City State Zip Phone: ( ) Social Security number: / / DOB: / / address: Signature: Date: / / 4 of 5

5 VOLUNTEER STATEMENT OF CONFIDENTIALITY 3100 East Fletcher Ave. Tampa, FL I,, understand the basic principles of confidentiality of patient and 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 5