Name: (Last) (First) (Middle Initial) Sex: F M Today s Date: Date of Birth: Street Address: City: State: Zip: Contact #: Teen s

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1 Application A Teen Volunteer may serve DeKalb Medical between the ages of 14 and in the 9 th grade 18. He or she will work within the hospital under the supervision of specified hospital personnel and the DeKalb Medical Auxiliary. PLEASE fill out form and print Name: (Last) (First) (Middle Initial) Sex: F M Today s Date: Date of Birth: Street Address: City: State: Zip: Contact #: Teen s Father/Guardian: Mother/Guardian: Contact #: Contact #: School: Grade: GPA: Special Interests: Honors or Organizations: Why would you like to be a Teen Volunteer? Do you have an interest in a health career? If yes, explain. Page 1 of 8

2 Please print Summer Volunteen Program Emergency Information On occasion we need to contact a relative or physician in case of emergency. It is important that the Volunteer Services department have this information. Name of Volunteer Date of Birth Street Address: City: State: Zip: Home Phone: Cell Phone: Teen s address: ****************************************************************************** Emergency Contact 1: Name Relationship Home Phone: Cell Phone: Work Phone: Emergency Contact 2: Name Relationship Home Phone: Cell Phone: Work Phone: ****************************************************************************** Doctor s Name Doctor s Office Phone / / Date form completed Page 2 of 8

3 ALL documents must be received by deadline of March 31, in one packet to be invited to an interview: Emergency Information Sealed doctor s letter with immunization record Sealed Counselor/Teacher recommendation form with academic achievement and GPA Sealed personal recommendation form Parent s agreement, signed First 50 qualified, complete packets will be invited for an interview. To hand deliver, please call or for directions to office. Phone: Fax: karen.caughman@dekalbmedical.org Or mail to: DeKalb Medical Foundation & Volunteer Services 2701 North Decatur Road Decatur, GA Page 3 of 8

4 COUNSELOR/TEACHER RECOMMENDATION FORM DATE Dear Counselor/Teacher: has applied for membership in the Volunteen Program at DeKalb Medical. Would you please comment on this student's record in the following areas: Conduct? Ability to follow instructions? Tardiness? Absenteeism? Other information? Would you recommend this student for the Teen Volunteer Program? Counselor's/Teacher s Signature Please provide a copy of transcript with GPA. Place both recommendation form and copy of transcript in a sealed envelope and RETURNED TO APPLICANT. Page 4 of 8

5 DOCTOR S RECOMMENDATION FORM Date Dear Doctor: has applied for membership in the Summer Volunteen Program at DeKalb Medical. I agree this Teen has no physical, emotional, or mental, limitations, which would interfere with the applicant s ability to function in the hospital environment. I disagree this Teen has no physical, emotional, or mental limitations, which would interfere with the applicant s ability to function in the hospital environment. Please sign this form, include a copy of the patient s immunization records and place in a sealed envelope RETURN TO APPLICANT. Your reply will be held in confidence and is an important factor in considering this person for the Teen Summer Volunteer program. Thank you for your assistance. Comments: Doctor s Signature Date Page 5 of 8

6 PARENT S AGREEMENT I hereby permit my son/daughter to join the Teen Summer Volunteer Program at DeKalb Medical. I realize the responsibilities of the organization and will cooperate with my son/daughter to comply with the rules and regulations which have been adopted. I will assume responsibility for his/her transportation. In the event of a medical emergency, I permit the physicians in the Emergency Department of DeKalb Medical to treat my son/daughter. Parent's Signature Date Please list any allergies or chronic illnesses: Page 6 of 8

7 PERSONAL RECOMMENDATION FORM has expressed a desire to join the Summer Volunteen Program at DeKalb Medical. Each applicant must submit two letters of recommendation from a principal, teacher, clergyman, or any other unrelated person (over 18 years of age) who knows the teenager well. Please write a brief statement of recommendation regarding this prospective Volunteen character, general attitude, dependability, personality and ability to cooperate and follow instructions. An additional page may be used, if necessary. If you have any questions, please contact the DeKalb Medical Foundation & Volunteer Services Office at or via at karen.caughman@dekalbmedical.org. Thank you for assisting us in this matter. Please Print Name Relation to applicant Home Phone Work Phone Cell Phone Signature: Date: Comments: (Continue on back if more space is needed.) Please put your recommendation form in a sealed envelope and RETURN TO APPLICANT. Page 7 of 8

8 TB SKIN TESTS (to be done after interview but before Orientation) Tuberculin (TB) skin tests are required of all persons working and volunteering at DeKalb Medical. The TB-skin tests are administered free of charge by the Occupational Health Department to all prospective volunteers. To make an appointment please call TB-skin test results have to be read within hours after administration of the test. You are not allowed to volunteer until we have the results of your TB-skin test. A second test is required within 2 weeks of the first test. However, you may begin volunteering after we have received the 1 st test results. Teen volunteers need to bring a note from a parent or guardian giving the Occupational Health Department at DeKalb Medical permission to administer the TB-skin test. If you know that you test positive for TB, you need to fill out a TB questionnaire at the Occupational Health Department at DeKalb Medical. Depending on when your last chest x-ray was, you may need a chest x-ray. Page 8 of 8

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