2018 Junior Volunteer Application (Please PRINT Use either blue or black ink All information must be completed by Junior Applicant)
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2 Office Use Only Received By: Date Received: / /. Complete Incomplete Interviewed By: Date Interviewed: Accepted Not Accepted 2018 Junior Volunteer Application (Please PRINT Use either blue or black ink All information must be completed by Junior Applicant) SELECT ONE SESSION A: June 4 June 29 SESSION B: July 2 July 27 NAME: (Please Print) (First) (MI) (Last) Applicant s Cell Phone: Applicant s Address: School Attending: Year of Graduation: Will you be 15 years old by the first day of the session you have selected? Yes No List any summer activities that would interfere with your volunteering this summer: (such as vacation, summer school, internship, job, camp, holidays, etc.) Do you have a family member who works or volunteers at Memorial Hermann Katy Hospital? Yes No If yes, please provide the following information: Name: Relationship: Department/Area: Contact Number: How did you hear about our Junior Volunteer Program? Prior volunteer experience: Where: How Long? Where: How Long? Where: How Long? Applications are on a first come first served basis and will not be accepted once the program is full Junior Application Page 1
3 Applicant s Name: (Please Print) Why do you want to volunteer at Memorial Hermann Katy Hospital? What do you hope to gain from your volunteer experience? Are you volunteering to meet requirements for a specific reason? (i.e. community service hours, school requirements, etc.) Yes No If yes, please explain: Emergency Contact Information Name: Contact Number: Cell Home Work Relationship: Please provide one additional EMERGENCY contact if we are unable to reach the person listed above: Name: Contact Number: Relationship: Cell Home Work There will be two (2) Junior Volunteer sessions! You will be required to volunteer for 32 hours during each 4-week session, 2 shifts and 8 hours per week. Each shift will be four (4) hours, Monday thru Friday either 9 am to 1 pm or 1 pm to 5 pm. Applications are on a first come first served basis and will not be accepted once the program is full Junior Application Page 2
4 Applicant s Name: (Please Print) Please select which session you would like to volunteer. When selecting a session, make sure you will not have any conflicts with any other activities for that session. You will not be permitted to miss any assigned shift, i.e. vacation, camp, family reunions, college visits, etc. You should plan your activities during the session that you will not be volunteering. If you miss any of your shifts, you may be dropped from the program and won t receive credit for hours volunteered or be able to apply for future sessions. Some exceptions may apply but that will be determined by the Junior Volunteer Coordinator and Volunteer Director. Scheduling is done according to the days/times that you indicate you are available to volunteer. Assignments are scheduled in the departments on the days/times they need a volunteer and day/time you are available. The more shift times you are available, the easier it is for us to schedule you at one of the times you are available. PLEASE SELECT ONLY ONE SESSION SESSION A SESSION B June 4 - June 29 July 2 - July 27 Mandatory orientation May 30 Mandatory orientation June 25 (If the Session you selected has no vacancies, would you be able to volunteer for the other Session without missing any days?) YES NO Please SELECT/CIRCLE the days and times you are available for the duration of the 4 weeks: Mondays 9:00 AM 1:00 PM 1:00 PM 5:00 PM Tuesdays 9:00 AM 1:00 PM 1:00 PM 5:00 PM Wednesdays 9:00 AM 1:00 PM 1:00 PM 5:00 PM Thursdays 9:00 AM 1:00 PM 1:00 PM 5:00 PM Fridays 9:00 AM 1:00 PM 1:00 PM 5:00 PM I understand that I MUST volunteer for a minimum of 32 hours without missing any assignments during the 4-week period. At least 8 hours per week are required to complete a minimum of 32 hours for the program. Applicant s Signature Parent/Guardian s Signature (If applicant is under 18) Applicant s Name (Please print clearly) Parent/Guardian s Name (Please print) Applications are on a first come first served basis and will not be accepted once the program is full Junior Application Page 3
5 JUNIOR VOLUNTEER AGREEMENT Attachment A If accepted as a Memorial Hermann Katy Hospital Junior Volunteer, I agree that: 1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient. 2. My services are donated to Memorial Hermann without contemplation of compensation or future employment. 3. I understand that a TB test is required prior to volunteering in any Memorial Hermann facility and must also be completed on an annual basis 4. I understand that I am to wear an authorized Memorial Hermann volunteer uniform and name badge, closed toe shoes and socks while volunteering. No blue jeans or denim of any color, or shorts are allowed. 5. I shall not solicit any business for outside organizations, including attorneys or insurance companies, either on or off hospital property. 6. I shall report all known occurrences of solicitation for attorneys to the Manager of Volunteer Services. 7. I understand that solicitation for charity, distribution of literature or distribution for sale of any type of goods, raffle tickets or the like, on Memorial Hermann owned or leased property will be prohibited at any time unless it is sponsored by the System. 8. I will not seek from Doctors or Nurses professional advice for myself or my family while on duty. The privilege of being a volunteer does "not" include medical service. 9. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality. 10. Should I have any problems related to my volunteer activities, I will contact the Junior Volunteer Coordinator or the Director of Volunteer Services. 11. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept. 12. I shall always uphold the Philosophy and Mission and Behavioral Expectations of Memorial Hermann Health System. 13. I understand that the Volunteer Services Department reserves the right to dismiss my volunteer status because of: (a) failure to comply with hospital policies, rules and regulations; (b) failure to meet attendance commitment; (c) unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the department director, would make my continued service as a volunteer contrary to the best interests of the hospital. By my signature, I acknowledge that I have read, understand and agree to adhere to the statements above. Applicant s Signature Applicant s Name (Please print clearly) Parent/Guardian s Signature (if applicant is under age 18) Parent/Guardian s Name (Please print) Junior Volunteer Coordinator or Director Volunteer Services Phase I 2018 Jr Volunteer Agreement Attachment A
6 POLO SHIRT SIZE ATTACHMENT B Applicant s Name: (Please Print) If accepted into the program, you will be required to purchase and wear a Memorial Hermann Junior Volunteer polo shirt. (Both male and female) These shirts will be available for purchase at orientation at a cost of $20. (non-refundable) Please circle the size that you will need. XS (Chest size 32-34) S (Chest size 35-37) M (Chest size 38-40) L (Chest size 41-43) XL (Chest size 44-46) XXL (Chest size 47-49) Other (Chest Size) How to measure: CHEST With arms down at sides, measure around the upper body, under arms and over the fullest part of the chest. NOTE: Sizes run large you may want to order a smaller size. Have you participated in the Memorial Hermann Katy Junior Volunteer Program previously? YES NO If Yes, what year(s)? Have you participated in the Katy Memorial Hermann Explorer Program? 2018 Polo shirt size New Junior Attachment B
7 Applicant s Name: (Please Print) The following must be completed and returned attached to your application in order to apply for a Junior Volunteer position. If any of the following is missing, your application will not be considered. 1. Junior Volunteer Application completed and signed. (Parent/Guardian must also sign page 3 if applicant under 18 years of age.) 2. Attachment A Junior Volunteer Agreement Read and Sign. (Parent/Guardian must also sign if applicant under 18 years of age.) 3. Attachment B Polo Shirt Size Fill out indicating size Applicant Check List Phase I
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