If you are 16 years of age or older and are interested in becoming a volunteer at CHI St. Luke's Health - The Vintage Hospital please complete this application.


Name and address


Demographic Information


Availability

Please list the day(s) and time(s) you are available to volunteer.



Language

Please list any languages you speak in addition to English.



Skills

Please list all skills that may be helpful in your volunteer assignment.



Interests and Hobbies

Please list your interests and hobbies.



Assignment Preferences

Please list your assignment preference(s) in order.



Employment Information

Please list your position, the hours you work and your business experience in the box provided below.



Emergency Contact


References

Please list any two local personal references (other than family members).



Qualifications

Have you ever been convicted of or been on deferred adjudication for, or are you now either awaiting trial for or on deferred adjudication for, a felony or misdemeanor?



Please Answer the Following Questions

Please list prior volunteer experience. Where did you hear about our program? Why do you want to volunteer at St. Luke's Hospital at The Vintage?



IF ACCEPTED AS A VOLUNTEER, I AGREE THAT:

Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide information concerning your character, reputation, personal characteristics, and mode of living. You may obtain a copy of this information upon written request.


I hereby certify that the information I provided in this application is true, complete and correct to the best of my knowledge and I understand that any information withheld or falsely provided in connection with the foregoing application shall be cause for rejection of this application or termination of volunteer status. I hereby authorize St. Luke's Hospital at The Vintage, without liability, to contact prior employers (present employers if authorized), schools or references I have given and authorize said employers, schools or reference to make full response to any inquiries by St. Luke's Hospital at The Vintage in connection with this application for volunteer service, including police records.


I understand and agree that as a condition of my acceptance into the St. Luke's Hospital at The Vintage Volunteer Program, I will be required to pass scheduled physical examinations as they relate to my ability to discharge my duties. I HAVE READ, UNDERSTAND, AND AGREE TO THE FOREGOING PARAGRAPHS.


1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient.


2. My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian, religious or charitable reasons.


3. I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, both on or off of hospital property, or act as a runner or capper for an attorney in the solicitation of business. I shall report all known occurrences of solicitation for attorneys to the Supervisor of Volunteer Services.


4. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on St. Luke's Hospital at The Vintage Premises.


5. I shall submit to examinations, which may include chest X-rays, skin tests, appropriate laboratory tests and/or immunizations, as a part of my volunteer service. I hereby authorize my doctor(s) to furnish the hospital information concerning my health. I also authorize the person(s) making tests or X-ray films to report the results to the hospital.


6. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality.


7. I shall attempt to resolve any problems related to my volunteer activities with the unit/department supervisor and if unsuccessful, attempt to resolve any such problems with the Supervisor of Volunteer Services.


8. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept.


9. I shall at all times uphold the mission of St. Luke's Hospital at The Vintage.


10. I understand that Volunteer Services reserves the right to terminate my volunteer status as a result of:

(a) failure to comply with hospital policies, rules and regulations;

(b) 3 absences without prior notification;

(c) unsatisfactory attitude, work or appearance; or

(d) any other circumstance which, in the judgement of the Supervisorr of Volunteer Services, would make my continued service as a volunteer contrary to the best interests of the hospital.


I HAVE READ EACH OF THE ABOVE CONDITIONS AND AGREE TO ADHERE TO THEM.