ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: Elizabeth Seton Pediatric Center Volunteer Application Package
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1 ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: Elizabeth Seton Pediatric Center Volunteer Application Package
2 Volunteer Application Package Instructions Thank you for your willingness to volunteer with Elizabeth Seton Pediatric Center. To ensure the safety of our residents and staff, all individuals must go through the volunteer application process and be approved before beginning a volunteer assignment. The application process includes a background check through our vendor. Please complete the Volunteer Application Package in its entirety. Please ensure that all signatures fields are signed in this package. Please Do NOT staple forms when submitting them! Please send forms Except the Medical Papers directly to: Elizabeth Seton Pediatric Center Vanessa Andrews Volunteer Services 300 Corporate Blvd. South Yonkers, NY vandrews@setonpediatric.org To successfully complete the Volunteer Application Package, please follow these instructions: 1. Print out the volunteer application packet Complete all of the required information and signatures. Include your address in order to receive notification of approval. 2. Attach a copy of your driver s license or other legal photo identification to your application. The application requires a copy of your driver s license or other photo ID that includes your legal name, date of birth, height and weight. This helps to verify your identity in the background check process. Please complete all information on the background check forms. 3. Medical Examination Form. Please complete its entirety and submit all questions or communication regarding medical requirements to the Employee Health Nurse. Shauna Beharie, RN Elizabeth Seton Pediatric Center 300 Corporate Blvd. South Yonkers, NY Phone: Fax: Sbeharie@setonpediatric.org 4. Volunteer Reference Questionnaire. You will need to provide three (3) references. This form should be given to a Professional/Educator to whom you are not related. The individual reference should complete the form and return it to Elizabeth Seton Pediatric Center, Attention: Vanessa Andrews. Please use the attached reference questionnaire document and make copies for your references.
3 ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: PERSONAL INFORMATION (PLEASE PRINT) Name (Last, First, MI) Social Security Number Address Apt. # City State Zip Code Telephone ( ) Emergency Contact Emergency Telephone ( ) Have you ever been convicted of a crime? Yes No Are any criminal charges pending against you? Yes No If yes, explain fully, Have you been convicted of child abuse? Yes No Are any charges of abuse, neglect or maltreatment of a child currently pending against you? Yes No If Yes, explain fully, How were you referred to Elizabeth Seton Pediatric Center? Referred by Center for Pediatric Employee Name Relationship to you School Name Internet Newspaper Ad Other ACADEMIC BACKGROUND School (High School or College): Dates Attended: From to Address City State Zip Code Status (freshman, sophomore, junior, senior, graduate): Major: Graduation Date: Degree Earned/Sought: School (High School or College): GPA: Dates Attended: From to Address City State Zip Code Status (freshman, sophomore, junior, senior, graduate): Major: Graduation Date: Degree Earned/Sought: GPA: PREVIOUS VOLUNTEER HISTORY Agency Name: Telephone ( ) Address City State Zip Code Type of Service: Days Volunteered: Interests or special skills you would like to share:
4 What are your learning objectives for this placement and in what way will this experience allow you to accomplish these objectives? List any language (other than English) that you speak fluently: Days & Time Available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Volunteer work preferences: Clerical Skills (Typing, filing, phone receptionist, etc.) Patient Care Services as applicable to organization (Reading to patients, companionship, etc.) Personal Skills to Use or Teach: (Drawing, painting, crafts, gardening, etc.) Additional Skills: REFERENCES List 2 Business/School and Personal Name and Address (Include City & State) Occupation Telephone Number Company I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to termination of volunteer from the Elizabeth Seton Pediatric Center whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Student s Signature: Date: Note: Please send attached reference forms with letter to your 3 references and ask them to forward the references directly to: Elizabeth Seton Pediatric Center Vanessa Andrews Volunteer Services 300 Corporate Blvd. South Yonkers, NY vandrews@setonpediatric.org Please DO NOT Staple
5 ELIZABETH SETON PEDIATRIC CENTER APPLICANT MEDICAL FORM Instructions: Please complete page 2. Your physical exam (page 3) will need to be completed by a physician or nurse practitioner. Your completed forms need to be accompanied by your immunization records OR a copy of titers (a blood draw showing that you have the immunities that you would have received as a result of immunizations). The following immunizations are required: Measles Mumps 2 doses of live vaccine Rubella Varicella (chicken pox) 2 doses or titers proving that you have had the illness Tetanus (latest booster within last 10 years) DTaP, DT, Tdap, or Tp are acceptable Hepatitis B 3 doses Flu (during Flu season October through May) Proof of one negative PPD is required (given in the last 6 months). If you have had a positive PPD then your test results must be accompanied by a negative chest x-ray. We will administer the second PPD on your first day of internship. Please mail/fax this form along with your proof of immunizations directly to the employee health nurse: Shauna Beharie, RN Elizabeth Seton Pediatric Center 300 Corporate Blvd. South Yonkers, NY Phone: (914) Fax: (914) All questions or communication regarding medical requirements should be made directly to the employee health nurse. Page 1 of 3
6 MEDICAL HISTORY Completed by Applicant Name Date of Birth Address City State Zip Telephone # Address Job Title Emergency Contact Person Emergency Phone # PAST HISTORY Have you had any of the following? (INDICATE Y FOR YES, N FOR NO) Asthma Depression Hepatitis Thyroid Disease Arthritis Eczema High Blood Pressure Tuberculosis Bronchitis Epilepsy / Seizures Immune Disease Ulcers Cancer Fainting/Dizziness Kidney Disease Varicose Veins Chronic Cough Heart Disease Pneumonia Other: Colitis Headaches Rheumatic Fever Diabetes Hemorrhoids Shortness of Breath Have you had any hospitalization or surgery? (List Dates, Diagnoses) What medications are you taking? (List Name of Drug, Dosage, and Frequency. Include EPI PEN in this list) Do you have allergies to: (Medications, Foods, Latex, Insect Stings, or Etc.) Please list all: Do you/ Did you use Tobacco? YES NO IF YES, ( # packs / day x # yrs) How often do you drink alcoholic beverages? ( #drinks / day / wk / month) FAMILY MEDICAL HISTORY: (Cancer, Diabetes, Heart Disease, High Blood Pressure, other) MOTHER: FATHER: SIBLING: GRANDPARENT: SYSTEM REVIEW (Check the box) Neuro: Headache Dizziness Seizures Visual Problems Chest: Pain Palpitations SOB Cough Blood in Sputum GI: Stomach Ache Rectal Pain Blood Constipation Diarrhea GU: Pain on Urination Frequency on Urination Blood in Urine Musculoskeletal: Joint Pain Back Problems Deformities Menstruation: Regular Irregular Menopause LMP Last Pap Test Mammogram Breast Self-Exam Comments: I certify that I am free from a health impairment that would present a risk to the residents or which might interfere with the performance of my duties. I further certify that I am free from habit or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances that might alter my behavior. I hereby certify that all statements and answers provided by me on this examination form are complete and true to the best of my knowledge. I understand and agree that my appointment to the Pediatric Center is conditional upon full disclosure of all medical information and the failure to do so shall constitute grounds for immediate termination of employment. Signature Print Name Date Page 2 of 3
7 ELIZABETH SETON PEDIATRIC CENTER PHYSICAL EXAMINATION (Completed by Physician) VITAL SIGNS: T P R BP HT WT General Appearance: Skin: HEENT: Spine: Lungs: Heart: Abdomen: Extremities: Neurological: REQUIRED VACCINATIONS AND TITERS: IMMUNIZATION DATE ADMINISTERED TITERS TITERS MEASURED Varicella Rubella Measles Mumps TDAP PPD# 1 Date Planted: Site: Lot #: Exp. Date: Date Read: mm: Negative: Positive: CHEST X- RAY (If positive PPD results) Date: Negative: Positive: RECOMMENDED IMMUNIZATION DATES: Hep B Influenza Signature of Examiner Date Review & Complete (Initials) PPD #2 (Can be provided by ESPC after initial visit) PPD# 1 Date Planted: Site: Lot #: Exp. Date: Date Read: mm: Negative: Positive: Signature of Examiner Date Page 3 of 3
8 VOLUNTEER REFERENCE QUESTIONAIRE Applicant Name: TO THE VOLUNTEER APPLICANT: This form should be given to a Professional/Educational to whom you are not related. The individual reference should complete the form and return it to Elizabeth Seton Pediatric Center. TO THE REFERENCE: The person name above is applying to become a volunteer at Elizabeth Seton Pediatric Center. Please complete this questionnaire and return it to ESPC via , Attention: Elizabeth Seton Pediatric Center Vanessa Andrews 300 Corporate Blvd. South Yonkers, NY vandrews@setonpediatric.org Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner?
9 How was the applicant s verbal and written communication? Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _
10 Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner? How was the applicant s verbal and written communication?
11 Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _
12 Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner? How was the applicant s verbal and written communication?
13 Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _
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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
Naturopathic Wellness Center
Naturopathic Wellness Center Ashley G. Lewin, N.D. Erica Waters, ND Mychael Seubert, ND Pediatric Intake Birth to 3 years Name Sex Date of Birth / / Age Parent(s)/Guardian(s) Address City/State/Zip Telephone
PATIENT REGISTRATION FORM
Natalie A. Nealeigh, PA-C PATIENT REGISTRATION FORM PATIENT INFORMATION (PLEASE PRINT) Last Name: First Name: MI: Street Address: City: State: Zip: Home #: Cell #: Work #: DOB: Age: Sex (M/F): Marital
TOS Health Questionnaire
Name Referring Physician Main Reason for Medical Evaluation of Injury/Length of symptoms: Is this a work related problem? Y N Are you right or left handed? Occupation What treatment have you received for
APPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet
Baton Rouge Community College Nurse Assisting (HCNA 1215) Program APPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED
Patient s Legal Name: Preferred Name: First Middle Last
Douglas County Dental Clinic Patient Registration Revised August 2016 We REQUIRE A Parent, Guardian, Or Other Legally Responsible Party To Complete & Sign all forms. Please provide a photo ID, Proof of
Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION
Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW
Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD
Renée Rinaldi, MD Dahlia Carr, MD Ami Ben-Artzi, MD RHEUMATOLOGY CONSUTLATION ARTHRITIC CONDITIONS AUTOIMMUNE DISEASES MUSCULOSKELETAL ULTRASOUND Name: First Name Last Name Social Security Number: Sex:
Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)
Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs
Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D
HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
The Home Doctor. Registration Checklist
The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
Patient Communication Request
Patient Communication Request Name: Date of Birth: Address: ZIP: Home Phone: Work Phone: Cell Phone: E-mail address: It is the policy of Capstone Family Practice to contact patients for any lab results.
Pediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
Kenilworth Public Schools Harding Elementary School 426 Boulevard Kenilworth, New Jersey
Assistant Dear Parent/Guardian: Harding Elementary School Kathleen Murphy Principal Ronald Bubnowski Assistant Principal Attached, please find the Kindergarten registration packet for the Kenilworth School
CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018
1 CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 CHECK LIST & INSTRUCTIONS FOR COMPLETING THIS FORM: This Medical Form is required EACH YEAR for every participant of Camp Wastahi. As a requirement
If you would like to volunteer in the Gift Shop as part of the Hospital Auxiliary, please call for additional information.
Dear Prospective Volunteer. Thank you for your interest in the volunteer program at Robert Wood Johnson University Hospital Rahway. We are happy to know that you are considering becoming a part of the
AGE Is the student age 18 or older? (If YES, please skip to signature section below) p YES p NO
New York Summer music FeStivaL PERMISSION FORM This form must be emailed or faxed to NYSMF before your arrival. StudentName _ Festival Year AGE Is the student age 18 or older? (If YES, please skip to signature
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
Health Clinic Policies:
Health Clinic Policies: Burris has one full time nurse on duty daily. The health of your student is our concern. Habits are formed in early childhood. These habits are important to growth, health, happiness
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Hello and Welcome! I truly look forward to working with you and your child on the journey towards optimal health. Warmly, Amanda H.
Hello and Welcome! Attached you will find pediatric intake forms. Before your child s scheduled appointment, please fill out the forms as thoroughly as possible. I know your time is valuable and by bringing
Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
Middle Tennessee State University MSN Program. Clinical/Student Requirements- Admission to MSN Program
Middle Tennessee State University MSN Program Clinical/Student Requirements- Admission to MSN Program The following are required documents that MUST be uploaded in Medatrax prior to beginning the MSN program.