2017 Summer Volunteen Program Application Checklist

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1 Application Checklist The 2017 Summer Volunteen Program will be held from June 5 July 27, 2017 (one four-hour shift Monday through Thursday), with a one-week break from July 3 July 7, Interviews will be held the week of March 20, You will be notified by mid-march, if you have been selected to interview. The following documents must be received ON or AFTER Tuesday, January 3, 2017 and NO LATER than the deadline of Tuesday, February 28, 2017, in one packet to be invited to interview: Completed Application Volunteen Emergency Contact Information Parental Agreement form, signed Authorization to Videotape, Photograph or Record form, signed Sealed Counselor/Teacher Recommendation form with Current Transcript and GPA (minimum 3.0) Sealed personal recommendation forms (two) Sealed Doctor s Recommendation form with Immunization Record A select number of applicants will be invited for an interview. Note: returning Volunteens have placement priority. To hand deliver, please call or for directions to office. Phone: Fax: karen.caughman@dekalbmedical.org Or mail to: Attn: Karen Caughman DeKalb Medical Foundation & Volunteer Services 2701 North Decatur Road Decatur, GA If invited to interview and age 18 or above, you must submit to a criminal background check If accepted into the program, T-SPOT blood test results must be completed by April 24, 2017 If accepted into the program, you and a parent or guardian MUST attend a mandatory Orientation on Thursday, May 4, 2017 from 6:00 8:00 p.m. Teen Signature: Teen Name (PRINT): Date: * Please note, if accepted into the program and placed in the NICU, Mother/Baby or Labor & Delivery departments, student must provide documentation of having received the Tdap vaccine.

2 Application A Teen Volunteer may serve DeKalb Medical between the ages of 14 and 18, and must have completed the 9 th grade. He or she will work within the hospital under the supervision of specified hospital personnel and the DeKalb Medical Auxiliary. PLEASE PRINT Name: (First) (Middle Initial) (Last) (Nick Name) Sex: F M Today s Date: Date of Birth: School: Grade: GPA: Teen s Teen s Home Phn: Teen s Cell Phn: Street Address: City: State: Zip: Mother/Guardian: Father/Guardian: Contact #: Contact #: Special Interests: Honors and Organizations: Why would you like to be a Teen Volunteer? Do you have an interest in a healthcare career*? If yes, explain. *Please note that DeKalb Medical does not offer volunteer opportunities in pediatrics, as we do not treat children at our facility.

3 Emergency Contact Information In case of an emergency, it is mandatory that the Foundation & Volunteer Services Department have this information on file: Please print: Name of Volunteen Date of Birth Address Home Phone Cell Phone Home Address City State Zip **************************************************************************************** Emergency Contact 1: Name Relationship Home Phone Work Phone Cell Phone address Emergency Contact 2: Name Relationship Home Phone Work Phone Cell Phone address **************************************************************************************** Primary Care Physician Physician Office Phone

4 Parental Agreement I hereby permit my son/daughter to participate in the Summer Volunteen Program at DeKalb Medical. I realize the responsibilities and mission of the organization and will cooperate with my son/daughter to comply with and understand the rules and regulations which have been adopted. I will assume responsibility for his/her transportation. In the event of a medical emergency, I permit the staff of the WorksWell department and/or the physicians in the Emergency Department of DeKalb Medical to treat my son/daughter. Parent's Signature Date Please list any allergies or chronic illnesses:

5 Summer Volunteen Program Authorization to Videotape, Photograph or Record Please complete the areas highlighted in yellow. The undersigned agrees that DeKalb Regional Healthcare System, which includes DeKalb Medical North Decatur, DeKalb Medical Downtown Decatur and DeKalb Medical Hillandale, its agents and assigns, may use in its advertising, promotional educational and publicity campaigns, videotape, photographs and recording of the undersigned. The undersigned acknowledges that the permission herein granted is unconditional and that such permission can be revoked only in writing by the undersigned. Any such revocation is to be accompanied by sufficient identification of the undersigned as will enable DeKalb Regional Healthcare System to identify the videotape, photograph or recording for which use permission is being withdrawn. The undersigned waives any and all claims, which it might have against DeKalb Medical for use of such videotape, photograph or recording whatsoever, either before or after any withdrawal of permission. Date: Name of person videotaped, photographed or recorded: (please print) Signature or guardian s signature: Street Address: City: State: Zip: Telephone number: ( ) Person requesting permission: Foundation & Volunteer Services Department

6 Counselor/Teacher Recommendation Form Please provide a copy of current transcript with GPA (minimum 3.0 required). Both recommendation form and a copy of the student s transcript must be enclosed in a sealed envelope and RETURNED TO APPLICANT. DATE Dear Counselor/Teacher: has applied for membership in the Volunteen Program at DeKalb Medical. Please comment on this student's record in the following areas (continue on back if more space is needed): Conduct: Ability to follow instructions: Tardiness: Absenteeism: Other information: Would you recommend this student for the Teen Volunteer Program? Counselor's/Teacher s Signature

7 Personal Recommendation Form has expressed a desire to join the Summer Volunteen Program at DeKalb Medical. Each applicant must submit two letters of recommendation from a principal, teacher, clergyman, or any other unrelated person (over 18 years of age) who knows the teenager well. Please write a brief statement of recommendation regarding this prospective Volunteen s character, general attitude, dependability, personality and ability to cooperate and follow instructions. An additional page may be used, if necessary. If you have any questions, please contact the DeKalb Medical Foundation & Volunteer Services Office at or via at karen.caughman@dekalbmedical.org. Thank you for assisting us in this matter. Please Print Name Relation to applicant Home Phone Work Phone Cell Phone Signature: Date: Comments: (Continue on back if more space is needed.) Please put your recommendation form in a sealed envelope and RETURN TO APPLICANT.

8 Personal Recommendation Form has expressed a desire to join the Summer Volunteen Program at DeKalb Medical. Each applicant must submit two letters of recommendation from a principal, teacher, clergyman, or any other unrelated person (over 18 years of age) who knows the teenager well. Please write a brief statement of recommendation regarding this prospective Volunteen s character, general attitude, dependability, personality and ability to cooperate and follow instructions. An additional page may be used, if necessary. If you have any questions, please contact the DeKalb Medical Foundation & Volunteer Services Office at or via at karen.caughman@dekalbmedical.org. Thank you for assisting us in this matter. Please Print Name Relation to applicant Home Phone Work Phone Cell Phone Signature: Date: Comments: (Continue on back if more space is needed.) Please put your recommendation form in a sealed envelope and RETURN TO APPLICANT.

9 Doctor s Recommendation Form Date: Dear Doctor: has applied for membership in the Summer Volunteen Program at DeKalb Medical. PLEASE CHECK THE FOLLOWING: This person has no physical, emotional, or mental limitations, which would interfere with the applicant s ability to function in the hospital environment. Check one: I agree I disagree This person is physically able to transport patients in wheelchairs. Check one: Yes No Please sign this form, include a copy of the patient s current immunization records, place in a sealed envelope and RETURN TO APPLICANT. Your reply will be held in confidence and is an important factor in considering this person for the Summer Volunteen program. Thank you for your assistance. Comments: Doctor s Signature Date _ Doctor s Name (PLEASE PRINT)

10 Schedule Information PLEASE NOTE SESSION SCHEDULE: Interviews will be held the week of March 20, The 2017 schedule is set from June 5 July 27, There will be a one week break from July 3 7, A mandatory Orientation for all Volunteens, to be accompanied by one parent or guardian, is scheduled for Thursday, May 4, 2017 from 6:00 PM 8:00 PM in the Theatre at DeKalb Medical. It is our experience that teens receive the most benefit from the Volunteen program if they participate consistently during the session. Please be aware, if your schedule does not allow you to commit to the full eight-week session, we recommend you do not apply for this program. We are unable to schedule make-ups. Please carefully consider whether you will have time to fully participate in this program. Once the summer session has started NO changes to the schedule can be made. Additionally, ONE excused absence is allowed during the eight-week session. While we will do our best to work around your schedule preferences, please note that schedule selections cannot be guaranteed. Returning teens have scheduling priority. Shifts are available Monday through Thursday, 9:00 AM to 1:00 PM or 1:00 PM to 5:00 PM. There are NO Friday shifts available. Scheduling and availability will be discussed during the interview.

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