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

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 ___

 Name ______________________________________Phone ___________

 Address __________________City ________________Zip _____________

 Name ______________________________________Phone ___________

 Address _________________City ________________Zip _____________

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

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               

 

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      Date

 



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         Volunteer Parent Signature (If Volunteer Under Age 18)   

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      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