2013 Teen Volunteer Program

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1 2013 Teen Volunteer Program Volunteer Services Office Dear Teen, Thank you for your interest in volunteering at. Students chosen to serve in our hospital will be those who can best represent our hospital as responsible young men and women. They will be expected to willingly participate and be fully engaged in activities. Newton Medical Center provides this opportunity for students to discover career fields and learn from professionals while attending sessions and performing assigned tasks. Requirements for Students Participating in the Teen Program Yes No Will you enter grades 10, 11, or 12 in the fall of 2013? Yes No Are you on grade level? Yes No Do you have a GPA of 80+? Yes No Is your summer calendar open for the schedule below? 2013 Teen Volunteer Sessions Students attend daily Monday thru Friday from 8:30 11:30 One week session (10 th grade students in the fall of 2013) June 3 7 Three week session (12 th grade students in the fall of 2013) June Two week session (11 th grade students in the fall of 2013) July 8-19 If you answered yes to all the above questions, please read and complete the following steps: 1. The Application Complete the Application (Pages 2 & 3) Mail the application by April 5, 2013 to Volunteer Services Office Faxed and ed applications will not be accepted 2. References Personal Reference (Page 4) Give the evaluation form to a non-relative who has known you for at least two years. Guidance Counselor Reference (Page 5) Give the evaluation form to a counselor who can verify your GPA 3. Personal Interview If your application is accepted, you will be notified when to come in with one or both of your parents or guardian 1

2 Page 2 Teen Volunteer Application (grades 10, 11, 12 in the fall of 2013) Based on my grade in the fall, I am applying to attend: Session 1 Session 2 Session 3 Last Name First Name Middle Street Address Gender (Please Circle) M F City Zip Cell Phone: Home Phone: Birthday (Month/Date/Year) Age Tag Number if you will be driving Grade and Name of School in fall of 2013 Emergency Contact: Relation: New NMC Teen Volunteer Returning Teen Volunteer Phone: Previous or current volunteer experience: School Activities: Honors and Awards: (Attach additional pages if needed) Special Skills and Talents Career Plans: Previous or current employment: Personal Reference (page 4) NAME: Guidance Counselor Reference (page 5) NAME: School Phone Phone Why do you want to be a Teen Volunteer? (Attach additional pages if needed) Medical Conditions that coordinators should be aware of: Family Physician Phone: INCOMPLETE OR ILLEGIBLE APPLICATIONS WILL NOT BE CONSIDERED 2

3 Page 3 Teen Program Volunteer Contract / Agreement Parent / Guardian I, the undersigned, have read the guidelines including the dress code, code of conduct and procedures. If chosen to participate in the program, I will help my student arrive on time and leave according to the planned schedule. I have read the information provided on the application and agree it is correct. I understand that students are expected to conduct themselves as responsible young men and women and any disciplinary action will result in dismissal from the program. I authorize Newton Medical Center to give emergency medical treatment to my son/daughter. If emergency treatment is required, I understand that I will be notified using the contact information I have provided and will come to the hospital as quickly as possible to be involved in the treatment of my child. Signature of Parent or Guardian Date Phone Student I, the undersigned, have read and understand the guidelines as stated in this application packet including the dress code, code of conduct and procedures. I have read the information provided on the application and agree it is correct. I understand that students are expected to conduct themselves as responsible young men and women and any disciplinary action will result in dismissal from the program. I agree that the information provided on this application is correct as of the date it was completed. Signature of Student Date 3

4 NEWTON MEDICAL CENTER Page HOSPITAL DRIVE Teen Program COVINGTON, GEORGIA Personal Reference Evaluation Form Regarding Phone Student s Name Address City Zip 1. Please indicate your evaluation of the applicant with a check mark in the appropriate fields. TRUSTWORTHINESS INITIATIVE LEADERSHIP MATURITY TEAM SKILLS DEPENDABILITY INTERPERSONAL SKILLS OUTSTANDING AVERAGE UNSATISFACTORY NOT OBSERVED 2. Summary Evaluation Recommend without Reservation Recommend Recommend with Reservation Do Not Recommend 3. How long have you known this student? 4. How do you know this student? 5. DO NOT RETURN this form to the student. Your responses are CONFIDENTIAL. Please return this reference form by April 6, 2013 to: Martha Taylor, CDVS Fax: Signature of Reference Provider Print Name Phone Date 4

5 2013Teen Program GUIDANCE COUNSELOR EVALUATION FORM Student Date Address City, Zip School Current Grade Level GPA for school year The student is on grade level. Yes No 1. Please indicate your evaluation of the student with a check mark in the appropriate fields. TRUSTWORTHINESS INITIATIVE LEADERSHIP MATURITY TEAM SKILLS DEPENDABILITY INTERPERSONAL SKILLS OUTSTANDING AVERAGE UNSATISFACTORY NOT OBSERVED 2. Summary Evaluation Recommend without Reservation Recommend Recommend with Reservation Do Not Recommend 3. DO NOT RETURN this form to the student. Your responses are CONFIDENTIAL. Please return this reference form by April 6, 2013 to: Martha Taylor, CDVS Fax: Guidance Counselor Signature Print Name School Phone Your evaluation is very important to us as we screen students for our summer program. We place great value on your assessment and thank you for giving the time to prepare it. 5

6 Frequently Asked Questions Am I eligible to be a Teen Volunteer? If you can answer yes to the following: Will you be in grade 10, 11, or 12 in the fall of 2013? Do you maintain a B or better grade average? Can you commit to the schedule for your session? Please do not apply if your schedule does not allow you to attend on the dates set for your grade level. May I volunteer additional hours beyond those assigned in the summer schedule? Due to the number of students in the program, additional hours are not available. Can I volunteer in more than one area? Teen volunteers are assigned areas of service and are expected to stay in the area for the session. Teen Volunteers who return the next year may be able to request their assignment. Is there a cost associated with volunteering? Each teen will need to purchase a Polo shirt with the hospital logo for $20. See dress code for the remainder of the uniform. You may be able to use the shirt you had last year if you participated. Are meals available for Teen Volunteers? No. Teen Volunteers are expected to have breakfast before they arrive at the hospital at 8:30 a.m. Students may have lunch in the cafeteria after signing out at 11:30 a.m. at their expense. Dress Code Teens wear the purchased Polo shirt tucked in, clean and pressed with no wrinkles. Long, khaki dress style pant. No jeans/denim, cargo, carpenter, Capri, stretch pants allowed. Windbreakers, athletic jackets, sweaters or sweatshirts are not permitted. A long-sleeve white or black t-shirt may be worn under the polo if the weather warrants it. Hospital issued picture ID badge must be worn on the right collar. This is part of the uniform and must be visible when you are serving at the hospital. Black or brown belt Tennis shoes white or black are acceptable Socks must be worn Teen must be well groomed, wearing a clean uniform Gentlemen must wear hair off the shoulder and neatly groomed. No facial hair is allowed. Ladies hair must be neatly coiffed. Nails must be natural and short in length. Polish must be modest, fresh and not chipped. No perfume, cologne or after shave is permitted Jewelry keep to a minimum o Watches are permitted o Girls may wear one pair of earrings no dangles or hoops o Guys are not permitted to have earrings o Visible tattoos or visible body piercing other than for earrings is not permitted o Small rings may be worn, limited to one per hand o A small necklace or chain is permitted 6 Code of Conduct Attitude and Behavior Always maintain a friendly, cooperative and professional attitude while serving in the hospital. Be willing to help with tasks and let staff know you are willing to help. Remember - no task is unimportant in the hospital.

7 Confidentiality is a Must! Matters concerning the hospital, patients and staff are NEVER to be discussed outside the hospital. You are ethically and legally bound to maintain confidentiality for any medical information. Smoking is not allowed on hospital property. Loitering in the hospital before, during or after your shift is not permitted. Please meet your ride promptly at 11:30 each day. Some classes may be extended but will be announced in advance so you can prepare for pickup. Teens are not allowed to leave the NMC campus while on duty. Chewing Gum is not allowed while on duty. Procedures Checking In/Out Sign in/out according to specific directions Exchanging Assignments Do not exchange assignments with other volunteers Absenteeism If you are unable to attend, please call the volunteer office at to report the absence and the reason for the absence. Attendance Requirements Students are required to attend each weekday from 8:30 11:30 during the assigned session. Transportation Teens must provide their transportation Certificate of Service You will receive a Certificate of Service upon completion of your service provided if your attendance meets the requirements. Your hours of service will be important when applying for scholarships, college admission and employment. You may contact us for letters of recommendations if you satisfactorily completed your service. ID Badges ID Badges must be worn at all times while in the hospital and turned in on the last day of your service. Certificate of completion will not be issued until the badges are returned. Valuables is not responsible for your valuables. Please leave them at home. Electronics Electronics including beeper, cell phones or any other electronic equipment are not permitted under any circumstances. You may provide your parents/guardians with the phone number of the receptionist s desk Termination of Service Any violation of conduct, dress code, or inappropriate behavior may result in immediate dismissal from the Teen program. Dismissal from the program is at the discretion of the Volunteer Services Director. 7

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