2017 VolunTEEN Scheduling Form. SHIRT SIZE: S M L XL XXL **sizes run big

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1 2017 VolunTEEN Scheduling Form NAME: PHONE #: SHIRT SIZE: S M L XL XXL **sizes run big Indicate below your preference of shift by numbering the blocks by 1 st, 2 nd and 3 rd choice. If you have two first choices, put a number 1 in each shift you are able to work. If you are flexible and do not have any preferences, indicate that also! We will do our best to accommodate your preferences. Shifts are from 10 a.m. - 3 p.m., Monday through Friday, with a 1-hour lunch break. We DO NOT have any weekend placements. SHIFT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 10 a.m. 3 p.m. Make certain that the eight-week session (June 5-July 28) does not conflict with any plans (i.e. vacation, band or camp) that you may have for the summer. You must be available for those eight weeks, missing no more than two shifts with prior notice. July 4 is a holiday and will not be counted as an absence. Children s offers VolunTEEN experiences at a few of our neighborhood locations. Please check any locations at which you would be interested in volunteering, if applicable. Mail your application to the hospital you would like to be considered for, as indicated on page 6. Duluth (Sports Medicine) Orthotics & Prosthetics Fabrication Lab Satellite Boulevard Town Center Urgent Care Hudson Bridge Sandy Plains (Rehabilitation) Snellville (Sports Medicine) 1

2 DATE Counselor/Teacher Recommendation Form Dear Counselor/Teacher: has applied for membership in the VolunTEEN Program at Children s Healthcare of Atlanta. Thank you for taking your valuable time to complete this evaluation. Your observations are an important part of this student s application. Would you please comment on this student's record in the following areas: Personal Qualities Attitude toward school Excellent Good Fair Poor Cooperation Always cooperates Cooperates Sometimes cooperates Poor Emotional maturity Very mature Age appropriate Sometimes immature Very immature Integrity Highly trustworthy Trustworthy Usually trustworthy Questionable Leadership potential Leader Can follow or lead Leads on occasion Rarely leads Reaction to criticism Excellent Good Fair Poor Responsible Very responsible Usually responsible Sometimes responsible Rarely Self confidence Healthy self-image Needs some support Seems overconfident Poor self-image Self control Excellent Good Fair Poor Sense of humor Highly developed Good Fair humor Poorly developed Warmth of personality Always friendly Usually friendly Occasionally friendly Rarely friendly Ability to work independently Consistently works well Needs help occasionally Needs help frequently Needs help Work Skills Class Participation Joins in readily Contributes some Wants to dominate Rarely contributes Ability to work in a group Always works well Sometimes Has difficulty Has great difficulty Ability to work Always works well Needs some help Needs help frequently Needs constant help independently Completes assignments on Consistently completes Usually completes Needs additional time Has difficulty time Follows directions Easily and accurately Needs some help Needs Rarely Takes initiative Always Usually Sometimes Rarely Attention span Actively engaged Attentive Variable attention Requires frequent redirection Social Skills Peer relations Role model Healthy relationship Occasional problems Relates poorly Relationships with adults Courteous Usually positive Occasional problems Shows little respect Concern for others Very considerate Considerate Usually considerate Rarely considerate Attitude toward school Excellent Good Fair Poor Classroom Conduct: Please comment on the student s behavior/attitude: Areas of greatest strengths and greatest needs: Would you recommend this student for the VolunTEEN Program? Evaluator s Name (please print): Phone: Evaluator s Signature: Date: Title: Please place this form in a sealed envelope and return to applicant. Thank you! 2

3 VolunTEEN Agreement I,, hereby agree to the following: I understand volunteers must be at least 15 years old by June 5, 2017 and must fulfill all Volunteer Services requirements before placement can occur. I will attend the required training in order to be involved in the VolunTEEN Program for the summer of I will notify the Volunteer Services office staff if I will be unable to attend. I will keep confidential any information that I obtain while in the hospital. I acknowledge that anything seen or heard while in the hospital is privileged and should not be repeated. I understand that any breach of confidentiality will cause my volunteer status to come under review by the Volunteer Services office. I agree to maintain the volunteer standards of Children s Healthcare of Atlanta. I acknowledge that Children s reserves the right to end my volunteer placement if these standards are not met, following a conference with a member of the Volunteer Services staff. I agree to have a TB (T-Spot*) blood draw test. I understand that if I do not turn in a completed TB blood draw test, I will not be permitted to volunteer on the first day and it will count as one of my two absences. I agree to wear the uniform required for my volunteer placement. The VolunTEEN uniform is a Children s Healthcare of Atlanta VolunTEEN Polo Shirt. It is to be worn with long khaki pants (no capris or shorts). I understand that if I am not wearing the proper attire I may be sent home to change. I agree to be assigned to a 5-hour shift one day per week (10a.m. 3p.m.) based on the needs of the hospital. I understand that I must volunteer at least six of my eight shifts. I agree to notify the Volunteer Services office of any unplanned absences. I understand that my volunteer placement may be ended if I am absent without notification. Signed: Date: Prospective VolunTEEN Signed: Date: Parent/Guardian *To authorize Premise Health, a Children s affiliate organization, to administer a T-Spot to your child, please sign the consent form on the following page. 3

4 Treatment and Medication History Consent and Patient Acknowledgment of the Notice of Privacy practices and Consent to Use and Disclose Health Information I consent to all necessary steps taken for examination, diagnosis and treatment. If at any time I have questions about my examination, diagnosis, or treatment, I will not proceed until my questions have been answered so that I am fully informed. I understand that giving the providers and nurses all relevant information is important to my proper diagnosis and treatment. I understand complete compliance with my provider's instructions is critical to the success of any treatment prescribed. If required by law, I acknowledge that I was provided with an opportunity of a copy of the Premise Health Notice of Privacy Practices regarding uses and disclosures of information regarding me and my health ( Health Information ). I hereby consent to the use and disclosure of my health information, for the purposes and activities permitted under the federal privacy and state privacy laws, which are described in the Premise Health Notice of Privacy Practices. I specifically authorize the release, to the fullest extent permitted by law, for treatment, payment or operations purposes as described in the Notice of Privacy Practices, of information regarding the results of any HIV/AIDS testing or treatment, mental health treatment and substance abuse treatment. I authorize Premise Health to release my health information to my health plan or to a health and wellness provider approved by my health plan for purposes of advising me concerning appropriate measures to maintain or improve my health or any condition reflected in my records. I authorize Premise Health to release information to my designated insurance plan for the purpose of health plan administration, including receiving or making payment for services rendered on my behalf. I understand a patient is responsible for all charges incurred, subject to contract and program rules, regardless of my insurance status. If it becomes necessary to send this account to collections, the patient will be responsible for all additional charges. I have read and do understand the above information. Patient/Personal Representative Signature Date Patient/Participant Name (please print) Date of Birth Relationship of Personal Representative (parent/legal guardian): FOR SITE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Patient did not sign or refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please describe: ) 4

5 MEDIA CONSENT FORM AND WAIVER AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR VIDEOTAPE) FOR MEDIA AND PUBLIC RELATIONS PURPOSES I hereby give consent to Children s Healthcare of Atlanta Inc. (hereinafter Children s ) to take and use images (photographs or videotape) or sounds recordings of me and/or the minor patient or person named below for whom I am giving consent, and disclose confidential patient information about me and/or the minor patient or person, to or in any public media, including radio, television, internet or print, or in a Children s publication. I understand that the intended use of such images and confidential information is for advertising, marketing, fundraising or promotional purposes of Children s. I understand that confidential information to be disclosed may include information about the patient s treatment at Children s obtained from interviews of the family, physicians and hospital personnel, or from the patient s medical records, including photographs, x-rays, videotapes and results of diagnostic studies, and I hereby waive the right to or interest in the confidentiality of this patient information or images taken and disclosed to the public, as contemplated in this release. I acknowledge that this consent and authorization for release of confidential information is being made solely for the benefit of Children s and without any expectation of compensation or other benefit to the minor patient or person or the family thereof. To the extent that any benefit accrues or might accrue to Children s from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits. I hereby release and forever discharge Children s (including without limitation all corporate affiliates and officers, directors, trustees, employees, medical staff members and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the information and materials described herein, and I hereby waive all rights and interest in and to such information and materials. I have been informed that once this information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying Children s in writing at: Marketing and Public Relations Department, 1699 Tullie Circle NE, Atlanta, Georgia Name of Minor Patient or Person (please print) Date of Birth of Minor Patient or Person Zip code Name of Consenting Individual, Parent or Guardian Relationship to Minor Patient or Person Phone number address Today s date Signature of Consenting Individual, Parent or Guardian 5

6 VolunTEEN Application Checklist KEEP FOR YOUR RECORDS The following information must be received ALL TOGETHER in a sealed envelope by 4:00 p.m. on February 24 th. All paperwork must be received for the application to be considered complete. Note that due to the limited volunteer positions the program may fill up prior to the deadline. All applicants will be notified by March 24 th if they are selected for the interview process. Scheduling Form Teacher/Counselor Recommendation Form VolunTEEN Agreement (signed by teen & parent/guardian) Premise Health Consent Form (signed by parent/guardian) MMR and TDap Immunization Records and Chickenpox Immunity (two immunization dates or a titer blood test) Photo Consent Form Copy of Photo I.D. If accepted, note that there will be a mandatory training at the campus in which you applied: Children s at Scottish Rite: Wednesday, May 31 st, 2:00pm 4:00pm Children s at Hughes Spalding: Wednesday, May 31 st, 10:30a.m. 1:30p.m. Children s at Egleston: Wednesday, May 31 th 2:00pm 4:00pm Mail or bring all information to the campus in which you applied. Egleston and Scottish Rite are accepting applications for satellite locations listed on the scheduling form. Hughes Spalding is only accepting applications for Hughes Spalding. As a reminder, you are only able to apply to ONE campus: Children's at Egleston Volunteer Services 1405 Clifton Road NE Atlanta, GA Children's at Hughes Spalding Volunteer Services 35 Jesse Hill Jr. Drive SE Atlanta, GA Children's at Scottish Rite Volunteer Services 1001 Johnson Ferry Road NE Atlanta, GA