Your talents and time can make a real difference in the lives of those we serve. Join us!

Saturday, June 11, 2016

Event Time: 8:30 a.m. – 3:00 p.m.

Volunteer Shift: 7:30 a.m. – 5 p.m.

Hutto High School
101 FM 685
Hutto, TX 78634

Volunteer Registration Form

First Name *

Last Name *

Employer *

Phone *

Email Address *

T-Shirt Size *

Non-Clinical Volunteer Roles

Clinical Volunteer Roles

Role Descriptions:

NON-CLINICAL

Setup Crew	Setup event on June 10, 2016 at Hutto High School, 8am – 5pm
Cleanup Crew	Tear down and cleanup at Hutto High School after the mission, arrive at 3 p.m.
Volunteer Registration	Check in volunteers upon arrival, manage additional forms *Note this shift starts at 7 AM but is only a 4-hour shift.
Greeter	Welcome patients and provide general information
Patient Registration	Check in patients and fill out forms upon arrival
Runners	Direct patients to various service locations and coordinate wait times
Patient Guide	Escort patients throughout entire care experience *required to attend orientation on June 10, 2016, 6:30pm at Hutto High School
Foot Washing	Perform foot washing for patients; sock and shoe distribution (1-2 hour rotating shifts)
Dental Area Assistant	This is a nonclinical role. Help check patients in for dental. Provide other general assistance in the dental area.
Breakfast/Lunch	Manage distribution of breakfast and box lunches and beverages to volunteers; manage volunteer break room
Crowd Control	Monitor crowd and ensure smooth sequence of events (Security provided by Hutto ISD; will work with ISD security)
Checkout/Discharge	Provide direction for scheduling follow-up care; distribute box lunch tickets; direct patients to Resource Navigation
Parking/Traffic	Manage and direct flow of car traffic (must be Seton Security; will work with ISD security)
Spiritual Guide	Spiritual/pastoral counseling and assist with morning blessing of the hands for volunteers (Seton Chaplain, Chaplain resident, Seton Cove, Mission Integration)
Resource Navigator	Navigators will assist patients by educating about available community resources
General Volunteer Partners	Medical Mission committee members, please sign up for this role. Partners have been designated and invited. Partners, please sign up in the is category and write in your business name and your role.
CLINICAL
Nurse for Vital Signs and Triage	Nurses check vital signs and triage patients before medical examinations; assess current list of medications
Nurses for medical exam assistance	Nurses assist physicians during medical examinations and in checking vitals and triage when needed
Nurses for Relief Pool
Clinical Assistant/Medical Assistant
Primary Care APN/PA
Primary Care Physician (Family Practice Practitioner)	Physicians provide medical examinations and clear patients for dental services
General Surgery Physician
General Surgery PA
Dermatology APN/PA
Dermatology Physician
Podiatry APN/PA
Podiatry Physician
Pulmonology Physician
Respiratory Therapist
Cardiology Physician
Cardiology APN/PA
Cardio Echo Techs
EKG Tech
Behavioral Health Physician
Behavioral Health APN/PA
Emergency Medical Volunteer
Phlebotomists	Blood draws
Lab Tech	Manage logistics of lab samples and results
Dentist	Dentists and dental students provide dental care (including checkups, cleanings, etc.)
Dental Hygienist	Provide dental care (including checkups, cleanings, etc.)
Dental Assistant
Pharmacist	Process prescriptions, dispense medications
Pharmacy Techs Partners	Process prescriptions Partners have been designated and invited. Partners, please sign up in the is category and write in your business name and your role.

Comments/Additional Information

Authorization for Photo and Media Release

1. I hereby authorize Ascension and its hospitals, affiliates, subsidiaries and contractors to photograph, interview, use and publish my photographic or video image, or the photographic or video image of my minor child(ren) or my property.

2. I understand that the photographic or video image, or media interview may be produced and released in any media form, including, but not limited to, internet, newspaper, television, radio and/or marketing materials, in whole or in part, with such alterations and changes as Ascension desires, and that the images or interview may appear separately or with my name or the name(s) of my minor child(ren) included in this Authorization.

3. I understand that the purpose of the use or release of the images and media interview will be for education, marketing or public relations purposes.

4. The use or release of the images or media interview may be made to the public through education, marketing and public relations efforts for commercial or noncommercial publications, exhibits, and/or on the intranet and internet.

5. I agree that all pictures, reproductions, negatives, tapes of any kind relating to the images, and materials relating to interviews are, and shall remain, the property of Ascension and its agents to whom permission has been granted. If I should receive any print, negative or other copy thereof, I shall not authorize its use by anyone else.

6. I agree that no advertisement, photograph or other material need be submitted to me for approval, and Ascension shall be without liability to me for any distortion or illusionary effect resulting from the publication of my video, picture, portrait, likeness, or comments.

7. I understand that my signing this Authorization does not obligate Ascension to make use of any photographic or video images or media interviews.

8. I understand that this Authorization can be revoked by me at any time by submitting a written request to Ascension Communications, 101 S. Hanley, Suite 1100, St. Louis, MO 63105.

9. I understand that my revocation will not apply in those instances in which Ascension has acted upon this Authorization prior to the revocation being received by Ascension.

10. I understand that the information released pursuant to this Authorization may be subject to re-disclosure and no longer protected by state and federal privacy laws.

11. I hereby release and discharge Ascension from any and all claims, actions, and demands arising out of or in connection with the use of any photographic or video images or media interviews without limitation.

12. I understand that Ascension cannot require me to sign this Authorization as a condition of providing treatment to me or my minor children or obtaining payment for treatment.

13. I understand that my signing this Authorization is voluntary, not a requirement of my employment at Ascension, and that I will not face any repercussions on my employment status if I so choose not to sign this Authorization.

14. If no specific date is indicated, this Authorization will expire in ten (10) years.

I have read and had the opportunity to have my questions answered and understand the above terms and conditions and hereby authorize Ascension and its hospitals, affiliates, subsidiaries and contractors to photograph, interview, videotape and publish named image as described in this release.

I have read and agree to the terms above. *

I agree

Confidentiality Agreement

I understand that in the performance of my duties as a volunteer for Seton and its affiliates (the Medical Center), I may have access to and be involved in the observation or gathering or processing of confidential patient and/or business information.

Confidential patient information includes all information, whether spoken, written, or electronic, pertaining to a patient, the patient's condition, and events surrounding the patient's hospitalization and payment for services provided.

Confidential business information includes all information whether spoken, written or electronic pertaining to Medical Center business plans, payroll/employee information and other information related to Medical Center operations.

I understand as a condition of my performance of duties for the Medical Center that I am required to maintain the confidentiality of this information at all times, including after my duties at the Medical Center have terminated.

I also understand and agree that I will only access information which is needed to perform my duties or when required by Seton's policy, federal or state law, or applicable regulation. I also understand that no patient identifiable information shall be included in any report that may be generated for any educational activities I may be participating in or in any other third party publication unless consented to by the patient or expressly authorized by the Medical Center.

I understand that Seton's computer systems are proprietary and are to be used by authorized individuals only. Authorized use of the network and electronic communications shall be consistent with Administrative and Human Resources policies and guidelines. Such systems are to be used for business and research purposes only. Personal activities utilizing the Seton's computer system are prohibited.

I understand the Medical Center reserves the right to monitor its computer systems and electronic communications or other use of such systems at any time, without notice, to ensure the systems are being used for appropriate business or research purposes. Anyone using these systems consents to such monitoring. If such monitoring reveals possible illegal activity or inappropriate use, it may result in loss of access privileges and/or discipline up to and including termination of employment or other relationship with the Medical Center or its affiliates.

I understand that inappropriate use of electronic communications includes, but is not limited to offensive, defamatory, obscene or inappropriate communication. Transmission of harassing messages or participation in unethical/illegal activities is strictly prohibited.

I understand electronic communication accounts and passwords are to be used by the designated authorized individual only and are not to be shared. I agree to not share my password with anyone.

I understand that a violation of these confidentiality considerations may result in disciplinary action, up to and including termination of my duties at Medical Center or its affiliates or termination of my employment. I further understand that I could be subject to legal action for breach of confidentiality.I have read and I understand the Medical Center confidentiality policy, and I will abide by its provisions.

I have read and agree to the terms above. *

I agree

Your Signature is Required:
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