College Volunteer Application

IMPORTANT INFORMATION REGARDING COLLEGE VOLUNTEER APPLICATION

Your application is not complete until all of the following documents have been turned in. ALL DOCUMENTS MUST BE TURNED IN AT THE SAME TIME. Do not mail documents separate, as they can get lost or separated from your file and then your application will not be complete.

 Completed College Volunteer Application (This must be printed and included in your packet)  Completed College Volunteer Health Review, which includes a TB (tuberculosis) test with a negative reading or a chest X-Ray if you have had a positive reading, from your physician.  Immunization Records that show you have had immunizations for MMR (Measles, Mumps and Rubella), Varicella (chicken pox), and Tdap (Tetanus, Diptheria and Pertussis). If you have not had the Varicella vaccination, but have had chicken pox, your doctor will need to run a Titer on you to prove you have had the illness. You must turn in these results with the rest of your application.  Medical Information and Authorization for Emergency Medical Care of Minors (if under 18).  Participation Release, Waiver and Indemnity Agreement  Background Release (KGriff) ONLY for those 18 years of age and older  One Page Essay on one of the Values -RICE (Reverence, Integrity, Compassion , Excellence)  2 letters of recommendations from teachers or a professional that is not related to you. (Do not let them mail the recommendation separate. Please have them hand it to you in a sealed envelope).  All accepted participants are required to attend a mandatory orientation on Tuesday, June 6, 2016 from 8 – 4 p.m. and will be required to participate the entire nine weeks of the program. All participants will be given one shift a week and will be allowed to only miss one shift during the nine weeks.

ALL REQUIRED DOCUMENTS ARE DUE ON APRIL 30TH, NO EXCEPTIONS.

All forms should be mailed together to:

Volunteer Services 17200 St. Luke’s Way, Suite 160 The Woodlands, TX 77384

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. Tuberculosis Screening Form

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. St. Luke's The Woodlands Hospital College Volunteer Health Review Certification Form

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. ______Date

Name: ______Male / Female Last First Middle Age circle one

Last 4 digits of Social Security #: ______Date of Birth: ______Cell Phone #______

In case of Emergency:

Notify: ______Name Relationship Phone Number

Physician’s Name: ______Phone Number

Immunization requirements as per Texas Senate Bill 7-Article 8 (“Adoption of Vaccine Preventable Diseases Policy by Health Care Facilities”)

Please provide current, completed shot record for review with documentation of the following:

TB skin tests – one TB skin test within past 12 months AND one TB symptom screen form (provided by occupational health) Chest X-ray – for + TB people only, record of chest x-ray within past 6 months TDAP or Td (vaccination within past 10 years) Varicella (2 vaccinations, lab evidence of immunity, OR MD documented history) MMR (2 vaccinations OR lab evidence of immunity)

To be filled out by PRIVATE PHYSICIAN:

Hospital policy requires a Mantoux Tuberculin Skin test within the last six months. You may go to your physician or to a clinic to have the test administered and interpreted. The following information must be documented on this form or your permanent immunization card.

Height: ______Weight: ______B/P: ______Pulse: ______Temperature: ______

Date PPD Placed______Date Read______Result : ______MM

Chest X-Ray Result (Required for Positive PPD, Must be within the last year)______Date______

Signature & Title of Doctor or Nurse reading PPD Skin Test and/or validating chest x-ray results:

Name: ______Title: ______(Signature only, No stamp) RN, LVN, or MD only)

Please List all prescription medications that you are currently taking:

______

Do you have any health concerns, which might limit your ability to perform your volunteer responsibilities? No Yes

______

Have you ever had or do you now have any of the conditions listed below? For all yes answers, list approximate date/year of treatment and explain treatment briefly. No Yes Explanation of Answer

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. Alcoholism ______

Arthritis ______

Asthma/Emphysema ______

Back Trouble ______

Cancer ______

Chest Pains ______

Diabetes ______

Drug Abuse ______

Epilepsy/Seizures ______

Fainting/Dizziness ______

Hernia ______

Hearing Problem ______

Heart Disease ______

Hepatitis ______

High Blood Pressure ______

High Cholesterol ______

Knee/Foot/Ankle/ Problem ______

Liver Disease ______

Nervous Breakdown/ ______Psychiatric Illness or treatment

Obesity (> 20 pounds overweight) ______

Stroke ______

Surgery ______

Ulcers ______

Vision Problem ______

Other ______

I hereby declare that my answers to the above questions are complete and true. I agree that any false statements shall be sufficient cause for dismissal. I hereby grant permission to St. Luke's Health Systems to investigate any information included in this form, and to contact my personal physician (listed on page 1 of this form) with regard to the information given. I understand that any information given to St. Luke's The Woodlands Hospital by myself or my physician will remain confidential.

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. ______Signature of Volunteer Date

For Volunteers Less than 18 Years of age the signature of a parent or legal guardian is required:

______Signature of Parent/Guardian Date

______Printed Name of Parent/Guardian Day Time Phone of Parent or Guardian

OCCUPATIONAL HEALTH CLEARANCE:

Date Outside Health Review Received:______

Date Junior Volunteer Cleared by Occupational Health:______

______Occupational Health Nurse

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. College Volunteers Health Screen Appointment

 Parent/Guardian signature on the “Junior Volunteer Health Review Certification Form” (for under age of 18 only)

 TB skin test documentation from within past 12 months Chest X-ray documentation within the past 6 months (for TB positive individuals) OR TSPOT or Quantiferon Gold (TB blood test) documentation

 TB symptom screen form

 MMR (Measles, Mumps, Rubella) – 2 vaccinations OR lab evidence of immunity

 Varicella (Chickenpox) – 2 vaccinations, lab evidence of immunity, OR MD documented history of chickenpox

 Copy of your most recent Tdap or Td vaccination (within past 10 years)

o Please note that the Tdap vaccination differs from the DTaP (pediatric) vaccinations

MEDICAL INFORMATION AND AUTHORIZATION

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. FOR EMERGENCY MEDICAL CARE

College Volunteer’s Name: ______DOB: ______

In case of an emergency, please notify:

Name: ______Relationship: ______

Home Phone: ______Work Phone: ______

Physician’s Name: ______Phone: ______

Overall Health:

List any known medical or physical conditions: ______

______

List any known allergies to food or medicine: ______

Date of most recent measles vaccination: ______(Must be since 1990)

List medications taken regularly: ______

______

Parental/Guardian Consent for Emergency Care:

The undersigned herewith authorizes St. Luke’s The Woodlands Hospital to provide any emergency care that might be needed in the event of injury or illness for ______, an unmarried person under 18 years of age still living at home and/or supported me.

Parent/Guardian: ______Date: ______(Signature)

REQUIRED HEALTH REVIEW

It is a hospital requirement that all volunteers have a health review that includes a TB (PPD) skin test as well as a copy of their immunization records. This completed form will be due to Volunteer Services with the completed application.

PARTICIPATION RELEASE, WAIVER, AND INDEMNITY AGREEMENT

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. In consideration of being allowed to participate on behalf of ______and related to events and activities, the undersigned acknowledges, appreciates and agrees that:

1. I KNOWLINGLY AND FREELY ASSUME ALL RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THOSE BEING RELEASED, or others and assume full responsibility for my participation and that of my child; and

2. I, for myself and on behalf of my child, heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS CHI St Luke’s The Woodlands Hospital, its officers, directors, agents, affiliates, and employees, other participants, sponsors, advertisers, and if applicable, owners of premises used to conduct any event(Releases) WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THOSE BEING RELEASED OR OTHERWISE , to the fullest extent permitted by law.

I ______have read and understand this release of liability and assumption of risk agreement, full y understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

______Signature ( Parent/Guardian if under 18) Date

I N V E S T I G A T I O N S & C I V I L P R O C E S S I N G KGriff

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. RELEASE AND AUTHORIZATION

In order to determine whether a candidate is suitable for a Volunteer position, it is necessary to thoroughly review your criminal background. Please carefully review the following paragraphs and sign and date the form below.

I, ______, hereby authorize St. Luke’s The Woodlands Hospital and/or their authorized agent, K. Griff Investigations, Inc., to contact any law enforcement agency, state agency, institution or private information bureau that has any record or knowledge of my worker’s compensation claims, medical exclusions/debarment or criminal history, in order to obtain or verify information on, but not limited to criminal history. I hereby authorize K. Griff Investigations, Inc., to release any so acquired information to St. Luke’s The Woodlands Hospital or its representatives. I hereby release St. Luke’s The Woodlands Hospital and K. Griff Investigations, Inc., their officers, employees, and agents, from any and all liability arising from the results of any investigation and the preparation of any reports concerning myself or my background. This authorization shall be valid one year from the date signed and a photographic copy of the authorization shall be as valid as the original. Permission is granted for information to be released by any state agency.

I waive any provision impeding the release of this information, and agree to provide any information necessary for the release of this information above and beyond that provided on the employment application.

If employed, I further authorize periodic checks of all above referenced sources as may be deemed necessary by employer.

______Full Name including maiden (Pls. Print) Social Security Number

______Address Driver’s License Number & State

______City/State/Zip Date of Birth

______Signature Date

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. 1925 Lexington Houston, Texas 77098 (713) 526-7711 Fax (713) 526-7730

1925 Lexington Houston, Texas 77098 (713) 526-7711 Fax (713) 526-7730

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. 1925 Lexington Houston, Texas 77098 (713) 526-7711 Fax (713) 526-7730

1925 Lexington Houston, Texas 77098 (713) 526-7711 Fax (713) 526-7730

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016. 1925 Lexington Houston, Texas 77098 (713) 526-7711 Fax (713) 526-7730

The Woodlands Hospital College Volunteer Application Packet Updated 01/04/2016.