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__ __ __ __ __ __ __ ___ __ __ __ __ __ ___ __ __ __ __ __ __ _____ __ __ __ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ ___ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __ _______________ ___ __ __ __ __ __ __ _________
Choose a hospital and service area(s) of interest:
Tulane Medical Center:
____ Information Desk/Admit Escort
____ Surgery Waiting Room
Patient Care Areas:
____ Cardio Vascular Recovery Area
____ Medical-Surgical
____ PACU (Recovery)
____ Emergency
____ Neuro/Stroke ICU
____ Cancer Center (outpatient clinic, Mon-Fri)
Tulane Lakeside Hospital :
____ Information Desk/Admit Escort
____ Surgery Wait Room
Patient Care Areas:
____ Emergency
____ Outpatient Surgery
____ Clinics (outpatient, Mon-Fri)
____ PACU (Recovery)
____ Postpartum or Medical-Surgical
AVAILABILITY: (If different from the time listed, fill in the time each day that you are available.)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning: 8-12:00p or 9-1:00p
Limited Limited
Afternoon:12-4:00p or 1-5:00p
Limited Limited
Evening
Until 9:00pm
Limited Limited Limited Limited Limited
How many days a week do you wish to volunteer: ________
I can begin service on: _______________ and available through _________________, _______
Upon completing an application for Volunteer Service, I understand and agree that:
- submitting this application form does not automatically enlist me as a Tulane or Tulane Lakeside Volunteer.
- by submitting this form, I attest that the information I have provided is true and accurate.
- it may be necessary to check references with previous employers or volunteer stations in order to fully evaluate my application.
- identity and volunteer eligibility verification must be produced prior to my acceptance as required by the Immigration Reform and Control Act of 1986.
- an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of
living, whichever may be applicable.
- any information received by the facility will be kept entirely confidential. If any negative or derogatory information is received in such report, I will be notified and have
the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
- if I accept a volunteer position with the facility, my position will be for no definite term and that either I, or the facility will have the right to terminate the volunteer
relationship at any time, with or without cause, and with or without notice.
- I will commit to completing 40 hours of service within 6 months or less.
I acknowledge that I am aware of the facility’s intent to check references and hereby authorize Tulane University Hospital & Clinic/HCA to contact my current/former employers
and/or volunteer stations.
Signed_______________ ______ ________________ Date__________ Parent/Guardian Signature if under 18 y/o:________________ ______ _____ ________
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