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Children s Hospital Junior Ambassador Program Application Packet for Summer 2018 Dates of Program June 11th through July 27th, 2018 Application Deadline March 5, 2018 Date: Name: (Last) (First)

1 Children s Hospital Junior Ambassador Program Application Packet for Summer 2018 Dates of Program June 11th through July 27th, 2018 Application Deadline March 5, 2018 Date: Name: (Last) (First) (Middle) Address: (Street) _ (City) (State) (Zip Code) Current Age: Date of Birth: Phone: cell: Parent/Guardian s Emergency Contact: Phone# Name High School: Graduation Year: Personal Interest Form I. How did you learn of the Children s Hospital Junior Ambassador Summer Program? II. Assignments: Which of the following duties would be of most interest to you? (Mark ALL that apply.) Greeting and escorting families and patients Assisting with wheelchair transport Circulating around patient areas with Hospitality Cart Circulating around patient areas with the Art Cart Providing support and service for patients and nursing staff on nursing units Delivering mail, flowers, and/or magazines to hospitalized children Assisting playroom coordinator during playroom activities Entering data into computers Providing clerical assistance (filing, copying, answering phones, etc.) Other areas of interest pg. 1

2 III. Availability: Junior Ambassadors schedule will be set up prior to the first day of orientation. A minimum of 20 hours each week for 6 of the 7 weeks is required. How many days per week do you plan to volunteer? Please indicate the days and times you prefer to be scheduled: TIMES Monday Tuesday Wednesday Thursday Friday 8am-12pm 1pm-5pm List date(s) and reason(s) you will not be able to volunteer (extracurricular, vacation, etc.) on certain dates during the 7-week Junior Ambassador Summer Program. IV. Provide three reasons why you would like to be a Junior Ambassador. (1) (2) (3) V. What does the phrase Patient Experience mean to you? VI. What skills and/or qualities would you bring to the Junior Ambassador Program? VII. What is your polo shirt size Adult: XS S M L XL 2XL pg. 2

3 Interview As part of the application process, you must complete an interview with Volunteer Services. Interviews must be scheduled and completed prior to March 30, Due to limited space, not all applicants will be interviewed and accepted into the program. Interview Tips: Be confident! Answer questions honestly and directly Practice answering the following question before: - If you could be an animal what would you be? - What do you like to do in your free time? - How would you describe your personality? - What are your values? - Why are you interested in being one of our ambassadors? - Why should we choose you to be an ambassador? - Talk about situations where you took a leadership role. - Name one difficult situation you have been in and how you dealt with it. Orientation To be considered for our Junior Ambassador Program all applicants must be able to attend the weeklong orientation, attendance is mandatory. Orientation dates and times are, June 11 through 15, 2018 from 9 AM until 3 PM. A meet and greet will be held the first day, starting at 9 AM. You will be provided with a Volunteer Handbook to read before orientation. Health Screenings If accepted into the Ambassador Program, you will be required to provide documentation of your immunizations and the following health screenings. Proof of receiving the childhood measles, mumps, rubella and varicella vaccines is NOT adequate for volunteering at Children s Hospital. 1. A one-time blood titer for the measles, mumps, rubella and varicella (chicken pox) MMR-VZV is required. If any titer is too low to have immunity then you will need to get another immunization for the low titer(s). 2. TB/PPD test results, signed by a health care professional. TB tests are good for one year and must not expire prior to August Documentation of all health screenings and additional immunizations for low titers must be completed and provided a minimum of two weeks prior to the first day of orientation. pg. 3

4 REFRENCES School and Community Each student who applies to the Children s Hospital Junior Ambassador Program must have two references. One is a school reference from your counselor or a teacher. The second is a personal reference from an adult in your community (not a relative). Please list the name and contact information of the adult in your community that has agreed to respond to an ed recommendation questionnaire. PRINT Name: address: Cell Phone: Please verify their address and please write legibly Please list the name and contact information of your school counselor or a teacher that has agreed to respond to an ed recommendation questionnaire. PRINT Counselor/Teacher Name: Address: School Phone Number: Please verify Counselor or Teacher s address and please write legibly I give permission for Children s Hospital Volunteer Services to request a recommendation from a community adult and a counselor/teacher at my school. I understand and agree that the information contained within the recommendation will be held confidential both from me and from the public. I authorize that all contained information may be released upon my request to the intended recipient of the recommendation. I further affirm and agree that community members and faculty members to whom this request is made shall be released from legal responsibility for any information given about what they believe to be an honest, candid and professional evaluation. Student s Signature: Date: Parent/Guardian s Signature: Date: Following review of all Junior Ambassador applications, an acknowledgement will be sent to you after March 10, 2018 to let you know if you ve progressed to the next step which is the interview process. Interviews must be scheduled and completed by March 30, Again, we regret that there is limited space available in our Junior Ambassador Program and that not applicants can be accepted. pg. 4

5 PRINT, SIGN, RETURN with Application Volunteer Contract IF ACCEPTED AS A HOSPITAL VOLUNTEER, I AGREE THAT: 1. I shall hold 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 or any staff. 2. My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian or charitable reasons. I will not ask to borrow money or accept monetary tips from any staff member, family member, or fellow volunteers. 3. I shall not sell or attempt to sell goods or services, request contributions, or to solicit persons to sign or distribute political petitions on hospital premises. 4. I shall submit to examinations, which may include chest x-rays, skin tests, appropriate lab tests and/or immunizations that may be necessary as part of my volunteer service. I hereby authorize my doctor(s) to furnish the hospital information concerning my health. I also authorize the person(s) making tests or x-ray films to report the results to the hospital. 5. I shall be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of others, and endeavor to make my work professional in quality. 6. I shall attempt to resolve any problems related to my volunteer activities with my supervisor, and, if unsuccessful, attempt to resolve any such problems with Director of Volunteer Services. 7. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept. I understand that I must complete 6 of the 7 weeks of the summer Junior Ambassador Program before I can receive credit for ANY hours or letters of recommendation. This includes hours needed for school, community service, etc. 8. I shall always uphold the philosophy and standards of the hospital and obey all hospital regulations, rules and policies as explained to me during the volunteer orientation. 9. I shall follow the dress code policy as outlined in the Ambassador Program and orientation. 10. I understand that the Volunteer Services Department reserves the right to terminate my volunteer status because of (a) failure to comply with hospital policies, rules and regulations; (b) absences without prior notification; (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. I have read and understand each of the above conditions and I agree to be bound by them. I have also read the VOLUNTEER HANDBOOK and agree to abide by the rules and regulations described therein. Volunteer Print Name Date Parent/Guardian Print Name Date Volunteer Signature Date Parent/Guardian Signature Date pg. 5

6 Revised 5/12/17 PRINT, SIGN, RETURN with Application Junior Ambassador Volunteer RULES AND REGULATIONS 1. If you volunteer for more than 6 hours, you will be given a scheduled lunch break. You must stay on the hospital grounds unless arrangements have been made with the Volunteer Department. 2. If you work less than six hours you may take a short break. You must check with the supervisor from your area to make sure it is a convenient time. 3. You must take your break in the cafeteria or a designated break area. You may not eat, drink, or chew gum in any patient care areas of the hospital which includes the Art Cart, playrooms and teen room. 4. You must remain in your assigned area unless on a break. If it is slow or there isn t enough work for you to do in your assigned area, you must come get permission from the Volunteer Services staff which includes the Duke University Intern. If no one is in the office, you may ask someone in Guest Services to page us but you must remain in your scheduled area. 5. No loud talking or laughing. No running or roughhousing in the hospital, even on scheduled breaks. We want you to enjoy yourself, but this is a hospital and appropriate behavior is expected always. 6. There should be no more than two volunteers with any patient at one time. If you are having a problem finding work to do, please check with your department supervisor or come to the Volunteer Services Department and we can help you. 7. If you are in a patient room, the door must remain open unless there is a valid reason for it to be closed. 8. Junior Ambassadors and volunteers are not allowed to use their cell phones in patient care or public areas. Cell phones can be used in break rooms, the volunteer office or cafeteria. 9. The volunteer uniform and nametag MUST be worn always. If you are at the hospital in a nonvolunteer capacity, you MUST NOT be in uniform. 10. Junior Ambassadors must commit to 6 of the 7-week summer program. No letters of recommendation will be written unless this commitment has been met. I have read and understand each of the above conditions and I agree to be bound by them. Volunteer Name (print) Volunteer Signature Date Parent/Guardian Signature Date pg. 6

Applicant Name: First Middle Last. Age: Birth Date: Applicant Cell Phone: Address Phone: Number & Street Name City Zip Code

PLEASE PRINT : Applicant Name: First Middle Last Age: Birth : Applicant Cell Phone: Address Phone: Number & Street Name City Zip Code (Applicant s) E-mail address: / Applicant s Parent s Legal Guardian/Mother/Father