2017 Summer High School Volunteer Program. Required Forms. Please return the following four forms (with required signatures) by Tuesday, February 14:

Transcription

1 2017 Summer High School Volunteer Program Required Forms Please return the following four forms (with required signatures) by Tuesday, February 14: 1. Consent for Pre-Participation Screening 2. Recommendation Form #1 3. Recommendation Form # Summer High School Volunteer Availability

2 Consent for Pre-Participation Screening Summer High School Volunteer Program Student s Name (Please Print): I consent to a pre-participation evaluation including but not limited to urine drug testing, tuberculosis (TB) test, and immunization documentation provided by your physician. I understand and agree that if I am offered the opportunity to participate with Nemours, the participation will be subject to successful completion of the urine drug testing and TB test provided by Nemours, and review of my immunization records. I authorize the release of the results of my urine drug testing and TB test and immunization records to Nemours, its operating divisions, and any agents or entities acting on its behalf. If the urine drug testing or TB test or immunization records discloses any misrepresentation or omission on my part or indicates, in Nemours sole discretion, that I am not suited for participation, my request may be rejected. I release Nemours and its operating division and agents from any and all claims, causes of action, and liabilities out of the results of these tests and screenings. I,, as legal guardian of the above minor, consent to the urine drug testing and TB test and review of immunization records of the above minor for the purpose of providing volunteer services with Nemours. Date Parent or Guardian Signature PLEASE NOTE: If the TB test proves positive, follow-up with your family doctor is required VS71 11/22/16

3 RECOMMENDATION FORM #1 (To be completed by someone who is NOT related to you) SUMMER HIGH SCHOOL VOLUNTEER PROGRAM TODAY S DATE: NAME OF APPLICANT: The above-named applicant is applying to become a volunteer in the 2017 Summer High School Volunteer Program at the Nemours/Alfred I. dupont Hospital for Children. Please complete the following reference information and give the form to the applicant who will return it to our office. How long have you known the applicant? In what capacity? Does he/she relate well with children? In what way? Does he/she relate well with peers and adults? Please evaluate the applicant related to the following: Very Poor Fair Good Good Excellent Reliability Honesty Integrity Initiative Following Directions Do you feel his/her attitude and personal appearance will contribute to our hospital s commitment to service excellence? In what way? What would you like us to know about the applicant that we haven t asked? NAME OF REFERENCE (Please Print): SIGNATURE OF REFERENCE: PLEASE NOTE: Return this form to the applicant as soon as possible. This Recommendation Form is a required component of a completed application. The applicant must submit your recommendation by the deadline on Tuesday, February 14, VS /22/2016

4 RECOMMENDATION FORM #2 (To be completed by someone who is NOT related to you) SUMMER HIGH SCHOOL VOLUNTEER PROGRAM TODAY S DATE: NAME OF APPLICANT: The above-named applicant is applying to become a volunteer in the 2016 Summer High School Volunteer Program at the Nemours/Alfred I. dupont Hospital for Children. Please complete the following reference information and give the form to the applicant who will return it to our office. How long have you known the applicant? In what capacity? Does he/she relate well with children? In what way? Does he/she relate well with peers and adults? Please evaluate the applicant related to the following: Very Poor Fair Good Good Excellent Reliability Honesty Integrity Initiative Following Directions Do you feel his/her attitude and personal appearance will contribute to our hospital s commitment to service excellence? In what way? What would you like us to know about the applicant that we haven t asked? NAME OF REFERENCE (Please Print): SIGNATURE OF REFERENCE: PLEASE NOTE: Return this form to the applicant as soon as possible. This Recommendation Form is a required component of a completed application. The applicant must submit your recommendation by the deadline on Tuesday, February 14, VS /22/2016

5 2017 Summer High School Volunteer Availability Name: Your input below will help us determine the day that you will be scheduled to volunteer. We will discuss your choice of day at your information session and will try our best to accommodate your request. CHOOSE THE DAYS THAT YOU ARE AVAILABLE TO VOLUNTEER 1. In the boxes below, please indicate the days that you would be available to volunteer during this summer s program. Place #1 in your first choice, #2 in your second choice, and #3 in your third choice. At a minimum, you must choose at least three days, and one of your choices must be either a Monday or a Friday. 2. You will be scheduled for one full day each week of the seven-week program. Remember, to fulfill your commitment you will volunteer a minimum of 6 weeks on the same day of the week and in the same assignments. I will volunteer one Full Day (9 a.m. to 3 p.m.) and am available on the following days. At a minimum, I have indicated THREE different days, and at least one of the days is either a Monday or a Friday. I have also indicated #1 for my first choice, #2 for my second choice, and #3 for my third choice. Monday Tuesday Wednesday Thursday Friday IMPORTANT: Once you have chosen the days you are available and submitted this paperwork, you may NOT change your choices. Doing so may force you to withdraw from the summer program. Please choose carefully, taking into account your other commitments for the summer. I have read and understand the above. To the best of my knowledge, the above information is correct. Student s Signature: Date: Parent s or Guardian s Signature: Date: VS /22/2017