Community Ambassador Coalition

VOLUNTEER INFORMATION

Gender

Preferred Pronouns

Name prefix

* First Name

Middle Initial

* Last Name

* Date of Birth

* Home Address

* City

* State

* Zip/postal

* Primary Phone

* E-mail Address

Drivers License

State Issued

* Social Security Number

Shirt Size

Language

Additional languages

Ethnicity

Special Accommodations: Do you need any special accommodations to fully participate in meetings or activities? (Language interpretation,wheelchair access, visual aids) Yes -Please Describe:

EMERGENCY CONTACT INFORMATION

* Primary Contact Name (First,Last)

* Relationship

* Primary Phone

* E-mail

VOLUNTEER INFORMATION

Please indicate your availability below:

Length able to commit

* First Date Available:

* Last Date Available

Please indicate your best availabilty:

Sunday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Monday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Tuesday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Wednesday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Thursday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Friday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

Saturday

8am-Noon

Noon-4pm

4pm-8pm

8pm-11pm

ORGANIZATION INFORMATION

Organization Name

Current Role

Organizational ExpertiseWhich communities or populations do you feel most connected to, either personally or professionally? (Open response: e.g., Black/African American, Latinx, youth, Rural communites, disablity communty, etc.) What Skills, experiences, or insights would you like to share as part of the coalition? (e.g., lived experience, public speaking, translation, organizing, policy, etc.)  

PHOTO RELEASE:

As a Harris Health volunteer, I realize that my image may be taken at hospital celebrations and other media events. I give my permission to the Harris Health System Director of Volunteer & Guest Services and the Administrative Director of Corporate Communications to use my image in any appropriate and related materials that will promote or otherwise publicize the Volunteer & Guest Services department or Harris Health.*

BACKGROUND CHECK AUTHORIZATION:

* I authorize Harris Health to conduct any and all inquiries necessary to determine my acceptability as a volunteer, including a thorough background check. I understand that this background check may include verification of personal and/or employment references, military information or police record inquiries.

* I am 18 years of age or older.

* By checking this box I agree to have Harris Health conduct a background check.

Please Select

Choose if you have ever been convicted of or been on defferred adjudication for, or are you now either awaiting trial for or on deferred adjudication for, a felony or misdemeanor.

List and explain convictions if any:

CONFIDENTIALITY AGREEMENT:

If accepted as a Harris Health Volunteer, I agree to the following:

* I agree to use confidential or proprietary information only as needed to perform my volunteer duties. This means I will not access confidential or proprietary information without legitimate need/permission, nor in any way divulge, copy, release, sell, lend, revise, alter, or destroy any confidential or proprietary information belonging to Harris Health System. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality.  

* I understand that my status as a Community Ambassador may be reviewed or revoked at the discretion of the CARE Executive Director for any of the following reasons:  1. Violation of confidentiality when confidentiality has been required or expected in the course of my participation.2. Consistent non-participation, including habitual absence from meetings, failure to engage, or lack of follow-through on agreed responsibilities.3. Conduct that is detrimental to the mission or reputation of the Coalition or Harris Health System  4. Unresolvable conflict of interest that materially interferes with my ability to serve in the Ambassador role.  

* I acknowledge that this role is based on trust, accountability, and a shared commitment to advancing equitable, community-informed care.for returning my badge and uniform to the volunteer and the Guest Services Department after completing my volunteer services.

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