2017 VolunTeen Application. Fort Belvoir Community Hospital

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1 Page VolunTeen Application Thank you for your interest in participating in the 2017 Summer VolunTeen Program! The American Red Cross got its start serving the United States Armed Forces and now you will be a part of that legacy. The VolunTeen program is one that requires time and effort to participate in. While everyone is not guaranteed a spot we try our hardest to accommodate as many people as we can. To ensure that you have the best experience and the best chance of being a part of our program please read all the way through our instructions and be sure to complete all steps on time. Below are the dates for the 2017 Summer VolunTeen Program, please pay attention and make note of due dates and meeting times, there will be no make ups or late applications accepted. 1 February 31 March, 2017 VolunTeen applications accepted 31 March, 2017 Completed VolunTeen applications must be submitted. *incomplete applications will not be accepted and no applications or parts of applications will be accepted after this date 12 May, 2017 Placements announced via *at this time all accepted applicants will receive an with next steps 23 June, 2017 All Occupational Health paperwork submitted to office and Red Cross online applications complete June & 5 July Orientation *you MUST attend one orientation 10 July 2017 Program starts 18 August Last day

2 Page2 Please mark the above dates on your calendar. Applications must be complete and submitted by 31 March. All accepted applicants MUST attend an orientation date. No exceptions will be made so please plan accordingly. A complete packet includes Item Due Date Date Completed 1. General Information Packet 3/31/ Parental Consent Form 3/31/ Essay 3/31/ Recommendations (min. 2) 3/31/ Medical Infor. Consent Form 3/31/2017 Volunteering Requirements Age eligibility: All volunteens must be present for the entire summer. If you are going to miss more than one week please inform one of the Red Cross Office staff. Volunteens must work a minimum of four (4) hours per shift Volunteens must work a minimum of eight (8) hours a week Recommendation Criteria: Must be a Teacher, Employer, Community Leader, Faith Based Leader or Healthcare Professional Hospital policy mandates that all staff and volunteers must be a U.S. Citizen

3 Page3 General Information Last Name First Middle Home Address City State Zip Code Home Phone Cell Phone Address Date of Birth (DD/MM/YYYY) Current Grade Emergency Contact Information (Parent or Legal Guardian): Name Relationship Address Phone Optional Information: Opportunity for VolunTeens are provided without regard to religion, creed, race, national origin, age or sex. This information is used only to determine diversity of Red Cross Volunteers. The United States EEOC uses ethnic grouping when requesting certain employment information. Gender: Male Female Race: Please check one of the following: American Indian Alaskan Native Asian/Pacific Black (not Hispanic Origin) Dual Ethnicity White (not Hispanic Origin) Hispanic Other

4 Page4 Current School Information School Name City/State Grade Level Date Attended Fluent Language Skills (include sign language) Interests (List activities which interest you or skills you possess) Volunteer Experience Organization Name Type of Experience # Months Provided Service Red Cross Certifications Type: Number: State: Exp. Date: Type: Number: State: Exp. Date: Previous Red Cross Experience Have you worked as a Red Cross volunteer in the past? Yes No Where and what did you do? Availability: Please specify days and shifts you are available to work this summer Monday Tuesday Wednesday Thursday Friday 8am-12pm 8am-12pm 8am-12pm 8am-12pm 8am-12pm 12pm-4pm 12pm-4pm 12pm-4pm 12pm-4pm 12pm-4pm List departments or areas of the hospital you are interested in working in:

5 Page5 Short Explaination: Why Do You Want to be a Red Cross VolunTEEN this Summer? ( words) Applicant Signature: Date: Staff Review/Initials: Date:

6 Page6 Medical Information Release Form Name: Date of Birth(DD/MM/YYYY): Address: City: State: Zip Code: Health Insurance Company: Doctor: Phone: Hospital: Phone: Dentist: Phone: Allergies: Medical Conditions: Medication Currently Taking: Name: Emergency Contact Information Relationship: Day Phone: Evening Phone: Other:

7 Page7 I recognize that my son/daughter may require emergency medical care. In the event of an injury/illness arising out of volunteer/job duties, FBCH offer to stabilize the injured individual. Any treatment necessary beyond initial stabilization will be coordinated by parent/legal guardian. I authorize the American Red Cross paid or volunteer staff to secure medical care and transportation as is necessary in their judgment. I assume responsibility for any medical and/or transportation bills incurred by my son/daughter en route to and or at a medical facility. I fully understand that every effort will be made to contact me as soon as possible, giving first priority to my son/daughter s medical care. Parent/Guardian Signature: Date: Medical Screening Additionally, in order to volunteer at, all volunteers must complete a medical screening and be cleared medically to volunteer through Occupational Health. The medical screening is required to participate in the VolunTEEN program are as follows: Review of medical history and immunizations Tuberculosis skin test (PPD) or exam (exam only given if a known converter) Blood Test for immunity to measles, mumps, rubella, hepatitis B and chickenpox Immunization for measles, mumps, rubella, chickenpox, hepatitis B (only certain volunteers), and tetanus/pertussis Job specific medical evaluations Testing and immunization are invasive medical procedures and therefore carry a small risk to the individual such as pain, itching, local swelling, infection, bleeding, allergic reaction, and shock. I understand that I, as the parent or guardian, must attend the medical screening events. I understand that the Occupational Health Clinic is the final authority for medical clearance for volunteers. I understand the risks and hereby give consent for in the mandatory medical screening. to participate Parent/Guardian Name (Please Print): Parent/Guardian Signature: Date:

8 Page8 VolunTEEN Program Parental Consent Form I,, do hereby give my consent for my child,, to participate in the American Red Cross VolunTEEN program at. I will allow him/her to be in any American Red Cross media promotions that may occur during his/her volunteer service. I understand that although all youth are strictly volunteers, they must adhere to the American Red Cross policies and the Code of Conduct, policies, and the VolunTEEN Program policies. I also understand that violations of these guidelines are grounds for dismissal from the VolunTEEN Program. VolunTEEN Signature: Date: Parent/Guardian Signature: Date: This Form Must Be Returned Before Volunteer Service Can Begin

9 Page9 Recommendation Form 1 (Recommending Person Must be a Teacher, Employer, Community Leader, Faith Based Leader or Healthcare Professional who is not related to the Volunteen) For the Student to Fill Out: First Name: Last Name: Grade: Program Applying For: Program Dates: For Recommender to Fill Out: Recommender s Name and/or Phone Number Relationship to Applicant How long have you known the applicant? Describe the Applicant (discuss academic achievement, character, etc. Please be specific) List strengths or unique qualities

10 Page10 Please check the appropriate column to describe applicant Academic Achievement Below Average Average Above Average Outstanding N/A or Unknown Concern for Others Creativity/Originality Independence/Initiative Leadership Oral Expression Written Expression Warmth of Personality Reaction to Criticism Overall Rating Please list any additional comments or thoughts here: Signature Date

11 Page11 Recommendation Form 2 (Recommending Person Must be a Teacher, Employer, Community Leader, Faith Based Leader or Healthcare Professional who is not related to the Volunteen) For the Student to Fill Out: First Name: Last Name: Grade: Program Applying For: Program Dates: For Recommender to Fill Out: Recommender s Name and/or Phone Number Relationship to Applicant How long have you known the applicant? Describe the Applicant (discuss academic achievement, character, etc. Please be specific) List strengths or unique qualities

12 Page12 Please check the appropriate column to describe applicant Academic Achievement Below Average Average Above Average Outstanding N/A or Unknown Concern for Others Creativity/Originality Independence/Initiative Leadership Oral Expression Written Expression Warmth of Personality Reaction to Criticism Overall Rating Please list any additional comments or thoughts here: Signature Date

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