Must provide copy of college/university enrollment confirmation.

Transcription

1 College Healthcare Volunteer Applicants: Thank you for your interest in the College Healthcare Volunteer Program in the ER at Memorial Hermann Katy Hospital during the period of June 4 July 29, We receive many applications and accept students based on their application, interview, placement availability and other factors. Criteria: Must have completed one full year at a college or university by June 2017 and be interested in the healthcare field, having completed courses to create a basic understanding of medicine or anatomy and physiology. Must provide copy of school issued picture ID. Must provide copy of college/university enrollment confirmation. Must complete College Healthcare Volunteer Application, Volunteer Contract and Volunteer Agreement Forms. Must undergo a mandatory background check. Must volunteer for the entire 8 weeks missing no assignments during this 8 week period. At least 8 hours per week (two 4 hour shifts) are required in order to complete a minimum of 64 hours for the program. If you do not complete your assigned hours you will not be given credit for any hours. If you cannot commit to volunteering twice a week for the entire 8 weeks, do not submit an application. Must attend orientation on May 18, 2018 from 1 p.m. to 5 p.m. and successfully complete a TB test if accepted into the program. It is IMPERATIVE to submit applications AS SOON AS POSSIBLE! We will only accept applications until we reach our set number of interview spots. Interviews will be conducted the weeks of March 5 and March 12. We will contact everyone by the end of March regarding program acceptance. Applications may be returned via: Heather.Rojas@memorialhermann.org Mail or Hand Delivered to: Memorial Hermann Katy Hospital ATTN: College Healthcare Volunteer Coordinator Katy Freeway Katy, TX Page 1

2 Returning Volunteer New Volunteer Office Use Only Received By: Date Received: / /. Complete Incomplete Interview Date Accepted Not Accepted Attended Orientation: Y N (Please PRINT) Name: (First) (MI) (Last) Home Address: City: Home Phone: Zip: Cell Phone: Applicant s School Currently Attending: Grade: Major: Year of Graduation: What classes have you taken that might prepare you for this experience? (i.e. Anatomy & Physiology, Medical Terminology, EMT, etc.) List your extra-curricular school activities: List your future goals: List any hobbies, talents or special interests: List any other summer activities that might conflict with volunteering: (i.e. summer school, internship, job, etc.) Page 2

3 Applicant s Name (Please Print) How did you hear about our Volunteer Program? Prior volunteer experience: Where: How Long? Where: How Long? Where: How Long? Where: How Long? Why do you want to volunteer at Memorial Hermann Katy? What do you hope to gain from your Volunteer experience? Are you volunteering to meet requirements for a specific reason? (i.e. community service hours, school requirements, etc.) No Yes If yes, please explain: Do you have a family member who works or volunteers at Memorial Hermann Katy? No Yes If yes, please provide the following information: Name: Relationship: Department: Contact Number: Name: Emergency Contact Information Cell Home Work Contact Number: Relationship: Page 3

4 Applicant s Name (Please Print) Interview Availability The only time we will interview, will be during Spring Break and you must be available: My Spring Break takes place the week of. Assignments If accepted to be a College Healthcare volunteer, you MUST volunteer for the entire 8 weeks without missing any assignments during the 8 week period. At least 8 hours per week are required in order to complete a minimum of 64 hours for the program. If you cannot commit to volunteering twice a week for the entire 8 weeks, please do not submit an application. Please SELECT/CIRCLE the days and times you are NOT available to volunteer for the duration of the 8 weeks: (We are looking for availability and flexibility in your schedule. You will be required to get a certain number of every type of shift: Weekday Days, Weekday Nights, Weekend Days, and Weekend Nights. You will be creating your own schedule, but we need to see that you will be available and flexible to get in all types of shifts). It will be required that a volunteer work at least some of all the different shifts. Days NOT Available Mondays Tuesdays Wednesdays Thursdays Fridays (weekend) Saturdays (weekend) Sundays (weekend) Day Shifts Night Shifts If I am accepted into the program, I am committing to the above. I understand that I MUST work the entire 8 weeks with a minimum of 8 hours per week. Applicant s Signature Applicant s Name (please print) NOTE: Completion of this application does not guarantee acceptance into the program. An incomplete application will NOT be considered. Please read all instructions and requirements and follow carefully. Page 4

5 College Healthcare Volunteer Contract PLEASE CAREFULLY REVIEW THE FOLLOWING AND INITIAL The following rules and regulations are MANDATORY: I am currently enrolled in a college or university and interested in the healthcare field, having completed courses to create a basic understanding of medicine or anatomy and physiology. I understand that I MUST volunteer for the entire 8 weeks without missing any assignments during this 8 week period. At least 8 hours per week is required in order to complete a minimum of 64 hours for the program. VOLUNTEER SERVICE COMMITMENT In submitting this application for volunteering in the College Healthcare Volunteer Program at Memorial Hermann Katy, I am aware that serving as a volunteer is a privilege carrying with it high trust and related obligations. I agree to fulfill my service commitment and to conform to all rules and regulations of the College Healthcare Volunteer Program. Please Initial: MEDIA CONSENT I understand that my photograph may be taken for the purpose of promotion of services at Memorial Hermann Katy, which is deemed appropriate. I am aware I will not receive payment of any kind for my participation and grant Memorial Hermann Katy the rights to use regardless of my future association with the facility and for an unrestricted time. Please Initial: CERTIFICATION AND AUTHORIZATION I hereby certify that all the information contained on this application is true and complete. I authorize Memorial Hermann Katy to contact all sources necessary to verify this information and to check references as deemed appropriate. I understand that any misstatement or omission on this application is cause for loss of volunteer privileges. Applicant s Name (Please Print) Applicant s Signature Date Page 5

6 College Healthcare Volunteer Agreement If accepted as a Memorial Hermann Katy College Healthcare Volunteer, I agree that: 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 Memorial Hermann Katy without contemplation of compensation or future employment. 3. I understand that I am to wear an authorized Memorial Hermann College Healthcare Volunteer uniform and name badge including closed toe shoes and socks while volunteering. No blue jeans or denim of any color or shorts are allowed. 4. I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, either on or off hospital property. 5. I shall report all known occurrences of solicitation for attorneys to the Manager of Volunteer Services. 6. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on hospital premises. 7. I will not seek from Doctors or Nurses professional advice for myself or my family while on duty. The privilege of being a volunteer does not include medical service. 8. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality. 9. Should I have any problems related to my volunteer activities, I will contact the College Healthcare Volunteer Coordinator or the Manager of Volunteer Services. 10. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I have been assigned. 11. I shall at all times uphold the Philosophy and Mission, and Behavioral Expectations of Memorial Hermann Healthcare System. 12. I understand that the College Healthcare Volunteer Coordinator/and or Manager of Volunteer Services reserves the right to terminate my volunteer status as a result of: (a) failure to comply with the hospital policies, rules and regulations; (b) failure to meet attendance commitment; (c) unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the department manager, 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 be bound by them. Applicant s Name (Please Print) Applicant s Signature Date Page 6

7 Applicant s Checklist Applicant s Name (Please Print) All of the following must be completed and returned to apply for a College Healthcare Volunteer position. If any of the following is missing, your application will not be considered. Please use this checklist to make sure everything is included in your packet: Copy of school issued picture ID Copy of college/university enrollment confirmation (can be a print out of your semester registration confirmation from your online account) 3. Completed and signed College Healthcare Volunteer Application (pages 2-4) 4. Completed and signed College Healthcare Volunteer Contract (page 5) 5. Signed College Healthcare Volunteer Agreement (page 6) Page 7