2018 Summer High School Volunteer Program. Required Forms. Please return the following four forms (with required signatures) by Wednesday, January 31:
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1 2018 Summer High School Volunteer Program Required Forms Please return the following four forms (with required signatures) by Wednesday, January 31: 1. Recommendation Form #1 2. Recommendation Form # Summer High School Volunteer Availability 4. Authorization to Release Photo/Video/Audio for Publication and Other Volunteer Activities
2 RECOMMENDATION FORM #1 (To be completed by someone who is NOT related to you) SUMMER HIGH SCHOOL VOLUNTEER PROGRAM TODAY S DATE: NAME OF APPLICANT: The above-named applicant is applying to become a volunteer in the 2018 Summer High School Volunteer Program at the Nemours/Alfred I. dupont Hospital for Children. Please complete the following reference information and give the form to the applicant who will return it to our office. How long have you known the applicant? In what capacity? Does he/she relate well with children? In what way? Does he/she relate well with peers and adults? Please evaluate the applicant related to the following: Very Poor Fair Good Good Excellent Reliability Honesty Integrity Initiative Following Directions Do you feel his/her attitude and personal appearance will contribute to our hospital s commitment to service excellence? In what way? What would you like us to know about the applicant that we haven t asked? NAME OF REFERENCE (Please Print): SIGNATURE OF REFERENCE: PLEASE NOTE: Return this form to the applicant as soon as possible. This Recommendation Form is a required component of a completed application. The applicant must submit your recommendation by the deadline on Wednesday, January 31, VS86.18 December 2017
3 RECOMMENDATION FORM #2 (To be completed by someone who is NOT related to you) SUMMER HIGH SCHOOL VOLUNTEER PROGRAM TODAY S DATE: NAME OF APPLICANT: The above-named applicant is applying to become a volunteer in the 2018 Summer High School Volunteer Program at the Nemours/Alfred I. dupont Hospital for Children. Please complete the following reference information and give the form to the applicant who will return it to our office. How long have you known the applicant? In what capacity? Does he/she relate well with children? In what way? Does he/she relate well with peers and adults? Please evaluate the applicant related to the following: Very Poor Fair Good Good Excellent Reliability Honesty Integrity Initiative Following Directions Do you feel his/her attitude and personal appearance will contribute to our hospital s commitment to service excellence? In what way? What would you like us to know about the applicant that we haven t asked? NAME OF REFERENCE (Please Print): SIGNATURE OF REFERENCE: PLEASE NOTE: Return this form to the applicant as soon as possible. This Recommendation Form is a required component of a completed application. The applicant must submit your recommendation by the deadline on Wednesday, January 31, VS86.18 December 2017
4 2018 Summer High School Volunteer Availability Name: Your input below will help us determine the day that you will be scheduled to volunteer. We will discuss your choice of day at your information session and will try our best to accommodate your request. CHOOSE THE DAYS THAT YOU ARE AVAILABLE TO VOLUNTEER 1. In the boxes below, please indicate the days that you would be available to volunteer during this summer s program. Place #1 in your first choice, #2 in your second choice, and #3 in your third choice. At a minimum, you must choose at least three days, and one of your choices must be either a Monday or a Friday. 2. You will be scheduled for one full day each week of the eight-week program. Remember, to fulfill your commitment you will volunteer a minimum of 7 weeks on the same day of the week and in the same assignments. I will be able to volunteer one Full Day (9 a.m. to 3:30 p.m.) and am available on the following days. At a minimum, I have indicated THREE different days, and at least ONE of the days is either a Monday or a Friday. I have also indicated #1 for my first choice, #2 for my second choice, and #3 for my third choice. Monday Tuesday Wednesday Thursday Friday IMPORTANT: Once you have chosen the days you are available and submitted this paperwork, you may NOT change your choices. Doing so may force you to withdraw from the summer program. Please choose carefully, taking into account your other commitments for the summer. I have read and understand the above. To the best of my knowledge, the above information is correct. Student s Signature: Date: Parent s or Guardian s Signature: Date: VS11.18 December 2017
5 Authorization to Release Photo/Video/Audio for Publication and Other Volunteer Activities For minors who are not Nemours patients, (18 years old or younger) Minor: D.O.B. (Last) (First) (M.I.) 1. I, (print name) am the parent or legal guardian of the above-named Minor and hereby authorize Nemours to USE AND/OR DISCLOSE the above-named minor s information and story with media outlets, social media channels and networks, advertising, websites, public marketing, promotional materials, training and/or presentation and other similar venues. 2. The following people and/or media organizations will have access: 3. This authorization will expire on: A specific date (if checked, enter the date), OR the following event/service: Agreement to use expires 10 years from date this form is signed. I understand that: I can change my mind and revoke this authorization, in writing, at any time, by sending a written revocation to the Nemours Privacy Officer at Centurion Parkway North, Jacksonville, Florida Information used or disclosed may be redistributed by the recipient and may no longer be protected by Federal or state confidentiality law. - It is common that disclosures for broadcast or publication will include posting the materials onto Web, social media, or similar sites. Once this occurs your information will be publicly available and freely distributed. I will receive a copy of this Authorization if requested. Signature of Legal Guardian Date Print Name of Legal Guardian Address Description of Personal Representative s Authority Home Phone # Cell Phone # To be completed by Nemours Associate: Purpose of photo/video: Situation in photo/video: Minor s gender (circle one): Male/Female Minor s description in photo/video (hair color, clothing): Name of staff person: Department: Nemours location: Date photo/video taken: 01053MC 10/2013
2017 Summer High School Volunteer Program. Required Forms. Please return the following four forms (with required signatures) by Tuesday, February 14:
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