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Giving
Volunteer Application Form

To become part of the St. Luke's Auxiliary, please complete and
sign the following volunteer application form. 

Once complete, send to
the address below:

St. Luke's Episcopal Hospital Auxiliary
6720 Bertner Ave. MC 4-279
Houston, Texas 77030-0629
832-355-2102 (office)

 

VOLUNTEER APPLICATION
Name_____________________________________________________
                 (last)                         (first)                      (m.i.)  
Other name (if applicable) _______________________________________
Address __________________________________________________
City_________________ZIP__________Home Phone___________
Social Security # __________________E-mail _______________

EMPLOYMENT INFORMATION
Current Employer (if applicable):____________________________
Address __________________________________________________
Phone ____________________
May we call you at work if necessary? Yes_______ No_______
Business Experience?_____________________________________

QUALIFICATIONS:
Level of Education: High School_____College______Trade School_____
Graduate School_____
College Major ________________________________________________
Name of current school _________________________________________
Grade Point Average______
Is volunteering a requirement for school credit? _______
Grade Point Average_____

 

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?
Yes ___ No ___
If yes, describe in full, including dates and locations._______________
_______________________________________________________
Conviction will not necessarily bar volunteer service.____________________
Prior Volunteer experience?______________________________________
Where did you hear about our program?_____________________________

PERSONAL DATA:
Special skills, talents, hobbies, interest
 ___Clerical
 ___Calligraphy
 ___Data Entry
 ___Computer
 ___Abstracting/Coding
 ___Crafts
 ___Art
 ___Typing
 ___Bookkeeping/Accounting
 ___Writing
 ___Music
 ___Public Speaking
 ___Photography
 ___Security
___Horticulture
Languages: __________________________________________________
Why do you want to volunteer at St. Luke's Episcopal Hospital?___________
___________________________________________________________
Would you be interested in helping the Auxiliary with extra projects such as
fund raising and special events? _____
Would you be willing to serve on the St. Luke's Episcopal Hospital Auxiliary
Board? _____

PLEASE LIST TWO LOCAL PERSONAL REFERENCES
(other than family members):
 Name ______________________________________Phone ___________
 Address __________________City ________________Zip _____________
 Name ______________________________________Phone ___________
 Address _________________City ________________Zip _____________
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 supplied in this application is true, complete,
and correct to the best of my knowledge and I understand that any information I
withheld or falsely provided in connection with the foregoing application shall be
cause of rejection of this application or termination of volunteer status. I hereby
authorize St. Luke’s Episcopal Hospital, 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 Episcopal Hospital 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
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.

_________________________
Volunteer Signature

 


INDICATE TIME AVAILABLE TO WORK:
 

8:30 - 11:30

11:30 - 2:30

2:30 - 5:30

5:30 - 8:30

Monday  



Tuesday  



Wednesday  



Thursday  



Friday  



Saturday  



Sunday  









IN AN EMERGENCY NOTIFY:
Name _______________________________________________________
Relationship ________________ Phone (work) __________(home)_______
Physicians name ________________________________Phone __________
Mailing Address _______________________________________________
IF ACCEPTED AS A ST. LUKE’S EPISCOPAL HOSPITAL 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 the hospital without contemplation of compensation or
    future employment, and given the 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 Director 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 hospital premises, unless I receive
    the express authorization of the Director of Volunteer Services to engage in these activities.
  5. I shall submit to examinations, which may include chest X-rays, skin tests, appropriate
    laboratory tests and/or immunizations, as 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 my
    supervisor, and, if unsuccessful, attempt to resolve any such problems with the
    Director of Volunteer Services and/or the President of the Auxiliary.
  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 the hospital.
  10. I understand that the volunteer services department 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 circumstances which, in the judgment of the
    department director, 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 I agree to be bound by them.
 ________________________________
   Volunteer Signature              

              .

      .

      .
____________________

      Date

 

      _______________________________

         Volunteer Parent Signature (If Volunteer Under Age 18) 

 _____________________

      Date

WITNESS CLAUSE

I agree that I have explained each of the conditions of volunteer services to the applicant
who has signed this form.                                                      

 ____________________________________



            Volunteer Services Department

      Representative Signature

 _____________________

      Date

 

Telephone Number 832-355-1000
Phone Number International
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