Palmetto Health Tuomey Student Volunteer Application Application to be completed by the student, NOT the parent. Full Name: Phone: (

Transcription

1 1 Palmetto Health Tuomey Student Volunteer Application Application to be completed by the student, NOT the parent. Full Name: Phone: ( ) address: Cell Phone: ( ) Address: City: Zip: Social Security Number: Parent name(s): Parent Employer: Parent Phone: ( ) Current school attending: Program (if applicable to Vol Svc) In Case of Emergency Notify: Phone: ( ) Physician s Name & Address: According to your shot record: MMR1 (Measles/Mumps/Rubella) Vaccine MMR2 Vaccine VERY IMPORTANT: Please provide two adult letters of reference, with Complete Telephone Number, Mailing Addresses and should we need to get in touch with them. (Do not include relatives) Previous Volunteer/Civic Experience: Education/Skills/Hobbies/Special Interests: Do you speak a foreign language or sign language? language: Have you been convicted of a crime other than minor traffic violation? Yes No If yes, provide details: Do you have any relatives employed at Palmetto Health Tuomey? Name, Relation and Department: Shirt Size (S, M, L, XL, XXL) I understand, if selected, I will be responsible for paying the cost of my uniform top -- $40. I hereby give Palmetto Health Tuomey permission to contact the listed references and release Palmetto Health Tuomey from any liability as a result of such contact. I understand that volunteer placement will be contingent upon completion of all initial and future health requirements as prescribed by Palmetto Health Tuomey Employee Health Department, reference checks, and completion of orientation and training requirements. Signature of Applicant: :

2 2 Student Volunteer MMR Form Name: Parental Permission: I give my permission for Palmetto Health Tuomey to give my son/daughter a Tuberculin Skin Test (PPD) during orientation and a second PPD 1 to 3 weeks later as required to satisfy the health requirements of the Junior Volunteer program. Another requirement is documentation of your teen s MMR 1 (measles, mumps, and rubella) vaccine. If you do not have the date for this vaccine, blood will have to be drawn to verify your child is immune. By signing this form, you are providing permission for this screening. If your son/daughter is 16 years old or older, we also need for you to record on this form the date he/she had a MMR 2. If he/she has not already had the MMR 2, we will provide the vaccine. A consent form will be sent to you. We wanted you to know that your son/daughter will be given information on the Hepatitis B vaccine which he/she is eligible to receive. This is not a mandatory vaccine and will be given only with your permission on a separate handout. Signature My child had the MMR 1 on:. MMR 2 on:.

3 3 Student Volunteer Essay/Parental Permission Form Attach your photo here Please share why you want to be a Student Volunteer at Palmetto Health Tuomey. In addition, please provide some information about yourself, such as your interests and goals. Tell us what kind of career you are working toward, and how it pertains to healthcare. I acknowledge that I have volunteered my services to Palmetto Health Tuomey with my parents /guardians permission and that I will accept only those service responsibilities which are within my physical and emotional capabilities. I, the parent/guardian authorize Palmetto Health Tuomey personnel to render any necessary emergency medical service to my son/ daughter while he/she is a participant in the hospital s volunteer program. We understand that volunteer placement will be contingent upon completion of all initial and future health requirements as prescribed by Palmetto Health Tuomey s Employee Health Department and completion of orientation and training requirements. Student Volunteer Parent

4 4 Student Volunteer Medical Form Student Volunteer Name: Birth date: Phone: Address: Address: SS#: Allergies: Family Physician: Past Medical problems of importance: (i.e. Seizures, Asthma, etc.): Any special needs we need to be aware of? Are you presently taking any medications? Yes No If so, what? Parent(s) Name(s): Father s Place of work: Phone: Mother s Place of work: Phone: In case of emergency, if parents are unavailable, Please notify: Phone: I, the parent, authorize Palmetto Health Tuomey personnel to render any necessary emergency medical services to my daughter/son while she/he is a participant in the hospital s Student Volunteer Program. Parent s Signature: :

5 5 Student Volunteer Academic Information 1. Name: 2. Age: 3. Grade: 4. Name of School: 5. What classes are you taking this semester? Grade/Average? Teacher Signature 6. Please list in order of preference, THREE medical careers you are interested in (we will do our best to match your preference with an appropriate experience): (1) (2) (3) 7. Are you involved in any other clubs or activities? (Please list) 8. Have you ever shadowed a professional in the hospital before? If yes, who or in what area? 9. Do you have any friends or family employed here at Palmetto Health Tuomey? If yes, please put their name and department: 10. Are you planning to attend college? If yes, which school? What is your intended major? Return completed application to: Palmetto Health Tuomey; Attn: Volunteer Services, 129 N. Washington St., Sumter, SC 29150, or to phtvolunteers@palmettohealth.org