Patient & Family Advisory Council Application

VOLUNTEER INFORMATION

Gender

Name prefix

* First Name

Middle Initial

* Last Name

* Date of Birth

* Home Address

* City

* State

* Zip Code

* Primary Phone

* E-mail Address

* Drivers License

* State Issued

* SSN

Shirt Size

Language

Additional languages

Ethnicity

Marital Status

EMERGENCY CONTACT INFORMATION

* Primary Contact Name (First,Last)

* Relationship

* Primary Phone

E-mail

Home Address

City

State

Zip Code

VOLUNTEER INFORMATION

Please select which Patient and Family Advisory Council you are interested in serving on:

Requested council - choose one (1)

Position Category

* Why would you like to be a part of our Patient and Family Advisory Councils at Harris Health?

Please summarize your volunteer and work experience:

* First date available to join council:

Meeting Attendance

EDUCATION AND EMPLOYMENT INFORMATION

Highest Level of Education

School/Major:

Employment Status

Company Name

Current Job Title

Business Experience

PHOTO RELEASE:

As a Harris Health Patient and Family Advisory Council member, I realize that my image may be taken at hospital celebrations and other media events. I give my permission to Harris Health to use my image in any appropriate and related materials that will promote or otherwise publicize my experience at Harris Health.*

BACKGROUND CHECK AUTHORIZATION:

* I authorize Harris Health to conduct any and all inquiries necessary to determine my acceptability as a Patient and Family Advisory Council member, 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:

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. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality.

If accepted as a Harris Health Patient and Family Advisory Council member, I agree to the following:

1. Understand that it is a crime to solicit business for attorneys and/or insurance companies.

* 2. Am donating my services to the hospital district without expectation of compensation and am not to solicit employment while performing my volunteer duties.

* 3. Understand that the Volunteeer Services Department does not assign volunteers to areas of professional or medical confilicts of interest.

* 4. Will not sell or attempt to sell any goods or services, solicit monetary or in-kind contributions, or collect/distribute petition signatures on Harris Health premises.

* 5. Understand that, I must never attempt to assess or diagnose any patients, nor shall I attempt to perform any medical procedures (i.e. draw blood, insert an IV and any other procedure that requires a medical license) on patients.

* 6. Understand that the Volunteer Services Department reserves that right to terminate my volunteer status as a result of: Failure to comply with Harris Health and departmental policies, rules and regulations; Unsatisfactory attitude, work or appearance/attire; Habitual tardiness and/or absences; and/or any behavior deemed unacceptable by any Harris Health facility, department supervisor and/or the Volunteer Services Department.

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