Clearance Form For Volunteer Work At St Lukes Roosevelt Hospital Center printable pdf download

Clearance Form For Volunteer Work At St Lukes Roosevelt Hospital Center

COLUMBIA COLLEGE

THE FU FOUNDATION SCHOOL OF ENGINEERING AND APPLIED SCIENCE

CLEARANCE FORM FOR VOLUNTEER WORK AT ST. LUKE'S-

ROOSEVELT HOSPITAL CENTER

I ____________________________________ (applicant’s name) authorize the Office of Judicial Affairs to release

my disciplinary records regarding incidents that resulted in a university sanction of probation, suspension, or

dismissal to the Center for Student Advising. I also authorize the Center for Student Advising to complete this form

which will be provided to St. Luke’s Roosevelt Hospital Volunteer Department.

UNI: _______________________ Graduation Year: _________ Phone: _________________________

This student is in good academic standing at Columbia College/SEAS.

Yes _______ No _________

If no, explain:

This student has been found guilty in a disciplinary matter.

Yes _______ No _________

If yes, explain:

This student's personal file indicates health problems.

Yes _______ No _________

If yes, explain:

MMR immunization printout attached.

Yes _______ No _________

If no, explain:

Student Name________________________Signature__________________________Date_________

Adviser Name ______________________ Signature ________________________ Date ________

Center for Student Advising

403 Lerner Hall, MC: 1201

(212) 854-6378

(212) 854-2562 (f)

Clearance Form For Volunteer Work At St Lukes Roosevelt Hospital Center