Summer Junior Volunteer Program Application. The application deadline is Tuesday, March 31, 2015.

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1 Summer Junior Volunteer Program Application Welcome! Thank you for submitting an application to be a part of the Harris Health System Summer Junior Volunteer Program. Volunteering can be a very rewarding and fulfilling experience that will stay with you throughout your life. You will need to read and submit this entire packet of information in order to be considered for placement in the Summer Junior Volunteer Program. Please also make sure you have completed the online form. Applicants will not be considered until all documents are received. The application deadline is Tuesday, March 31, If you are a returning volunteer, you do not need to complete this packet; however, you must submit an updated online application. Please contact your volunteer manager for any questions. If you have any questions, please do not hesitate to contact Aurora Miller, Intake Coordinator, or e mail [email protected]. APPLICATION CHECKLIST: Submit online application. Complete printed application. Personal Essay Submit a one page typed essay (at least 250 words) that addresses the following: What is your reason(s) for volunteering? What do you hope to gain from your volunteer experience? What other activities will you be involved with this summer? Will these interfere with volunteering at Harris Health? Complete and Sign Volunteer Agreement Form Complete and Sign Contract Agreement and Parental Consent Two Letters of Reference Forms Please have the form completed by someone outside your family such as your teachers, coaches, employers, etc. Vaccination Records A current vaccination record is required. All volunteers must present documentation of the following vaccines: MMR, Varicella, Tdap. In the case of a religious exemption, please contact the office for a form. Return the packet via (preferred as PDF document) or fax to the Harris Health Volunteer Office at [email protected] or fax to

2 If accepted as a Harris Health System Volunteer, I: Volunteer Agreement Form CONFIDENTIALITY AGREEMENT YOUR NAME 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 the Harris Health System. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality. Your Signature: Social Security Number: Today s 1. Understand that it is a crime to solicit business for attorneys and/or insurance companies. 2. Authorize Harris Health to provide me with a yearly TB skin test as part of my volunteer service. Should I test positive, I understand that I must provide the Volunteer & Guest Services Department with a letter from my physician stating that my TB is inactive before continuing with 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 & Guest 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 & Guest 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 & Guest Services Department reserves the right to terminate my volunteer status as a result of: Failure to comply with Harris Health, as well as, departmental policies, rules and regulations Unsatisfactory attitude, work or appearance/attire Habitual tardiness and/or absences Any behavior deemed unacceptable by any Harris Health facility, department supervisor and/or the Volunteer & Guest Services Department. 9. I understand that, I am responsible for returning my badge and uniform to the Volunteer & Guest Services Department after completing my volunteer services. Student Signature: Parent/Guardian Signature:

3 Summer Junior Volunteer Name: Phone Number: E mail Address: In signing this contract: Harris Health Summer Junior Volunteer Contract Agreement I will attend the MANDATORY Summer Junior Volunteer Orientation dates to be determined once accepted into the program. I will set up and adhere to a weekly schedule agreed upon with the Volunteer Manager. I will participate in any training required before beginning my service. I understand and will abide by the Summer Junior Volunteer Commitment of at least 4 hours (one shift) per week for the entire duration of the program. The program starts the week of June 17 and continues until August 9. I will always dress in the appropriate uniform khaki or black pants and a Junior Volunteer Polo shirt during my shift. As a Summer Junior Volunteer for Harris Health System, I realize that I not only represent myself, but also Harris Health and the Volunteer & Guest Services Department and I will perform my service with compassion, dedication and respect. If I fail to abide by the terms of this contract, I will not be eligible for a certificate of completion or a letter of recommendation, and may be dismissed from volunteering. Photo Release: As a volunteer at Harris Health System, I realize that my image may be taken at hospital celebrations and other media events. I give my permission to the Harris Health System Director of Volunteer & Guest Services and the Director of Corporate Communications to use my image in any appropriate and related materials that will promote or otherwise publicize the Harris Health System. Student Signature: Parent/Guardian Signature: Volunteer Coordinator: Parental Consent I give my consent for the Harris Health System Volunteer & Guest Service Department and the Employee Health Clinic Staff to evaluate on the job injuries and treat appropriately. My son/daughter is at least 14 years of age and will be entering the ninth grade in August 2013 but is not older than 18 years. I understand that if my son/daughter misses more than two shifts of unexcused absences he/she will be dropped from the program. Summer Junior Volunteer: Parent/Guardian:

4 Letter of Reference Form Please give to one of your teachers, counselors, employers, pastor, etc. Forms completed by relatives will not be accepted. (Name) has applied to the Summer Junior Volunteer Program at Harris Health System. Please complete the following information. Your evaluation will be an important factor in our selection process. All information is confidential and will not be disclosed to other parties. Name Address Phone Relationship to Applicant How long have you personally known the applicant? How well do you know the applicant? very well well casually other PLEASE CHECK THE FOLLOWING: General Characteristics Excellent Good Fair Poor Cleanliness, neatness/grooming Dependability Trustworthiness Punctuality Shows initiative Follows instructions Accepts constructive criticism Compatibility with peers Compatibility with adults What do you consider the applicant s special qualities of personality or character? Comments: (use reserve side, if needed) Signature:

5 Letter of Reference Form Please give to one of your teachers, counselors, employers, pastor, etc. Forms completed by relatives will not be accepted. (Name) has applied to the Summer Junior Volunteer Program at Harris Health System. Please complete the following information. Your evaluation will be an important factor in our selection process. All information is confidential and will not be disclosed to other parties. Name Address Phone Relationship to Applicant How long have you personally known the applicant? How well do you know the applicant? very well well casually other PLEASE CHECK THE FOLLOWING: General Characteristics Excellent Good Fair Poor Cleanliness, neatness/grooming Dependability Trustworthiness Punctuality Shows initiative Follows instructions Accepts constructive criticism Compatibility with peers Compatibility with adults What do you consider the applicant s special qualities of personality or character? Comments: (use reserve side, if needed) Signature: