Nash Health Care Junior Volunteer Application Packet

Transcription

1 We are delighted that you are interested in joining the Junior Volunteer Program here at Nash Health Care. This program offers students, ages 15-18, the opportunity to work in a professional environment and learn hands on skills that will help them in their future endeavors. The 2018 program will run June 11 th through August 17 th. Junior Volunteers are required to work a minimum of 60 hours. Attached you will find an Application, two Reference Forms and a Vaccination Questionnaire. Please fill out the Application completely and make sure that your parent or guardian has signed the form. Your Reference Forms must be filled out by two (2) current teachers in the School Year. Please note that references may not be completed by anyone who is related to you. There are a limited number of spaces in the Junior Volunteer Program. The deadline for submitting paperwork for the summer 2018 Junior Volunteer Program is Friday, April 20th. Once all applications are reviewed, we will begin calling chosen applicants in for interviews. All completed paperwork should be returned to: Nash Health Care 2460 Curtis Ellis Drive Rocky Mount, NC Please call at with any questions. We look forward to working with you!

2 Junior Volunteer Nash Health Application Care Packet Application Form Date: Shirt Size: Name: (Last) (First) (Middle) Mailing Address: Home Phone: Cell Phone: Address: Date of Birth: Age: Have you volunteered here before: School: Graduation Date: APPLICANT S STATEMENT: In your own words, tell us briefly why you want to be a Junior Volunteer at Nash Health Care. You may attach additional pages as necessary.

3 Application Form PARENT/GUARDIAN INFORMATION Name: Home Phone: Address: Work Phone: Cell Phone: Name: Home Phone: Address: Work Phone: Cell Phone: In case of emergency notify parent or guardian listed above or: Name: Relationship: Phone: APPLICANT AGREEMENT I hereby certify that the answers on this application and any resultant interviews are true and correct, and that misrepresentations or omission of facts, misleading or false information on my part will be grounds for dismissal as a volunteer. Acceptance as a Junior Volunteer is contingent upon satisfactory references, selection from the interview process and verification of the information submitted on this application. I, therefore, authorize you to make such investigations and inquiries as you deem necessary in arriving at a decision. I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer services herein applied for, and Nash Health Care is not obligated to assign or actively seek to assign volunteer services for me. I authorize that all employers, schools, or references thus contacted be released from all liability in answering inquiries related to my application. Application Signature Parent/Guardian Signature Date Date Opportunities for Junior Volunteers are provided without regard to race, gender, religion, national origin, sexual orientation, or disability. Junior Volunteers must meet minimum age requirement of 15 years old.

4 Junior Volunteer Reference Inquiry The Student named below has applied to the Junior Volunteer Program at Nash Health Care Systems and has requested that you provide a reference for him/her. This form should only be filled out by a current teacher. A reference completed by a teacher who is related to the applicant will not be accepted. Please remember that Nash Health Care is an acute care facility and that Junior Volunteers will interact with patients, families and hospital staff. Return this form at your earliest convenience. We cannot proceed with the application process until all reference forms are received. APPLICANT: Please check the appropriated boxes: PERSONAL EVALUATION OF APPLICANT PERSONAL QUALITY BELOW AVERAGE AVERAGE ABOVE Maturity Ability to work/interact with others/team Initiative Dependability Courteousness Ability to learn Ability to follow directions Neatness & professional appearance Quality of work Friendliness Positive Attitude Would you recommend that we accept this person into our Junior Volunteer Program? Yes No Please explain why or why not. You may attach additional pages as necessary. _ Name (Please print) Date: Signature: Work Phone: What is your relationship to the applicant, and how long have you known him/her?

5 Junior Volunteer Reference Inquiry The Student named below has applied to the Junior Volunteer Program at Nash Health Care Systems and has requested that you provide a reference for him/her. This form should only be filled out by a current teacher. A reference completed by a teacher who is related to the applicant will not be accepted. Please remember that Nash Health Care is an acute care facility and that Junior Volunteers will interact with patients, families and hospital staff. Return this form at your earliest convenience. We cannot proceed with the application process until all reference forms are received. APPLICANT: Please check the appropriated boxes: PERSONAL EVALUATION OF APPLICANT PERSONAL QUALITY BELOW AVERAGE AVERAGE ABOVE Maturity Ability to work/interact with others/team Initiative Dependability Courteousness Ability to learn Ability to follow directions Neatness & professional appearance Quality of work Friendliness Positive Attitude Would you recommend that we accept this person into our Junior Volunteer Program? Yes No Please explain why or why not. You may attach additional pages as necessary. _ Name (Please print) Date: Signature: Work Phone: What is your relationship to the applicant, and how long have you known him/her?

6 Junior Volunteer Vaccine Questionnaire _ Name (Last, First, Middle) Please print clearly Question 1 Do you have a vaccine record with verification of two MMR vaccines OR one vaccine for Mumps, one for Rubella (German Measles) and two vaccines for Rubeola (Red Measles)? Yes No If yes, please provide a copy of the record to. If no, please contact your personal physician to get an MMR titer to verify immunity, and provide confirmation to. Question 2 Have you had chicken pox? Yes No If yes, please enter approximate date or age: If no, have you had the chicken pox (varicella) vaccine? Yes No If yes, please provide a copy of the record to. If you have no history of the disease and have not been vaccinated for it, please contact your personal physician to get a chicken pox (varicella) titer to verify immunity, and provide confirmation of your immunity to. Question 3 Have you had a TB skin test in the past? Yes No If yes, when: Has your child ever had any reaction to a TB skin test? Yes No If yes, please describe: TB skin tests are MANDATORY for all employees, contract staff, and volunteers at Nash Health Care. If your child has not received a TB skin test in the past 12 months, please sign the consent below. If your child has received a TB skin test in the past 12 months, please provide confirmation to Volunteer Services. I authorize Nash Health Care s Occupational Health office to administer an initial TB skin test and a 2 nd test, if necessary and to collect a urine specimen for drug screen testing for: Age: (Child s Name) (Parent/Legal Guardian s Signature) Date: