Welcome to St. Peter's Health Partners

TEEN VOLUNTEER APPLICATION

VOLUNTEER INFORMATION:

* First name

* Last Name

Are you age 14 or above?

* DOB

* Address

Apt/Suite

* City

* State

* Zip/postal

Cell Phone

Home Phone

* E-mail

EMERGENCY CONTACT INFORMATION:

* Name

* Phone

* Relationship

AVAILABILITY AND ASSIGNMENT REQUEST:

Please list the times you are available to volunteer (HH:MM):

Times available:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Schedule Preference (Include day of week and time period)

First Choice

From(HH:MM):

To(HH:MM):

Second Choice

From(HH:MM):

To(HH:MM):

* Assignment Request

OTHER INFORMATION:

* How did you learn about the volunteer opportunities at Hospital for Special Care? What appealed to you about volunteering here?

* Why do you want to volunteer?

* What makes you a good candidate for HFSC's volunteer program?

* Are you volunteering in affiliation with an organization/church/school or special program?

INTERESTS/HOBBIES/SPECIAL SKILLS:

* Interests and Hobbies

Skills

Special Skills

Additional language(s) spoken:

EXPERIENCE:

Education

* Name of school

* Highest grade completed

* Diploma/Degree

Volunteer Experience

Agency Name

City/State

Type of Service

Dates

Agency Name

City/State

Type of Service

Dates

Do you belong to any clubs or community groups?

List any jobs that you have held:

Employer

Position

From:

To:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________

REQUEST FOR TUBERCULOSIS PRE-SCREENING TEST AT HOSPITAL FOR SPECIAL CARE

If your child is accepted into the Junior Volunteer Program, a Tuberculosis screening test (PPD) is required before beginning to volunteer. If your child has not had a Tuberculosis screening test (PPD) within the last three (3) months, the test may be administered by your family physician or other health facility who must provide us with documentation. Or screening tests are performed free of charge at Hospital for Special Care.

I give permission to have my child be provided the PPD test at HFSC (the screening test for Tuberculosis) with the understanding that my child will need to have the test area checked by the Hospital nurse 48 hours after administration.

My child has previously tested positive for Tuberculosis skin testing. My child has not had blood work done for quantiferon (lab test for exposure to TB). I give permisson for the quantiferon to be done by HFSC.

If my child receives a positive quantiferon result, I give permission to have my child receive a chest X-Ray at HFSC.

FLU

Hospital for Special Care requires all persons volunteering within our Facility to have a yearly influenza vaccine. We will accept documentation from other locations where your child received the flu vaccine such as CVS, Walgreens, or healthcare provider. The flu vaccine will also be available by appointment during the student's volunteer time. Volunteer Services will provide details upon request. A parental consent form will be provided.

IMMUNIZATIONS FOR MMR AND VARICELLA

If immunizations are unavailable or insufficient, I give permission for my child to have appropriate blood titers drawn via bloodwork at HFSC, free of charge.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name of Applicant

PARENT/GUARDIAN AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby give Hospital for Special Care the permission to request and obtain data pertinent to volunteering at HFSC from the above individual. I release from all liability or responsibility all persons and institutions supplying information. I authorize the hospital to make an investigation of any of the facts set forth in this application.

I grant permission for the applicant named above to participate in the Junior Volunteer Program at Hospital for Special Care. I understand that he/she must meet the health standards established by this hospital as a condition of initial and continued volunteer service which will be determined by the required health assessments. I understand that volunteer service at this hospital is "at will," which means that either he/she or the Hospital can terminate the volunteer service relationship at any time, with or without prior notice, and for any reason not prohibited by statute.

* My typed name below shall have the same force and effect as my written signature.

* E-mail OR phone

* Date

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

APPLICANT'S STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION

I certify that the facts set forth in this application are true, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of volunteer service or immediate termination of service, regardless of when or how discovered. I authorize the Hospital to make an investigation of any of the facts set forth in this application. I understand that I must meet the health standards established by this hospital as a condition of initial and continued volunteer service.

My typed name below shall have the same force and effect as my written signature.

* Signature

* Date