Teen Volunteer Program Application Overview Summer 2016 Thank you for your interest in the Teen Volunteer Services Program at Piedmont Medical Center! Joining the dedicated team of teen volunteers can be a very rewarding experience for you. We are quite proud of the many volunteers who make our program such a great success every day and appreciate your interest in assisting us this summer. Our summer program will begin in with orientation in June and continue through early August. Participation Qualifications In order to participate, you must: Be at least 14 years old; Submit a completed application, including all required forms; Return the application by either the priority deadline of Friday, April 15, 2016 or final deadline of Friday, May 6, 2016; Once accepted, attend orientation (June 6 th or June 13 th ) and have a TB screen performed at the hospital; Commit to no more than 2 weeks of absences in order to truly benefit from participating in the summer program. Once we have processed all applications, we will contact selected applicants to set up an interview regarding the volunteer process and where you will serve within the hospital. Application Components Below, you will find a downloadable application, a teacher recommendation form, and a health screen recap. Application Submission Options Online Submission: In order for your application to be considered, you must upload a completed teacher recommendation form and health screen recap when submitting your application.
Mail-In Submission: If you would like to mail in your application, please see the downloadable form. Once all components of the application are complete, you may send all components to: Piedmont Medical Center Marketing & Public Relations Department 222 South Herlong Avenue Rock Hill, SC 29732 You may also scan your completed application and email it to pmc.volunteers@tenethealth.com. Application Deadlines Priority Deadline: Friday, April 15, 2016 Final Deadline: Friday, May 6, 2016 We look forward to helping you pursue your interest in volunteering at Piedmont Medical Center. Sincerely, Susan Malette Volunteer Program Coordinator
Applicant Name Mobile Phone Number Email Address School Currently Attending &Grade Level Date of Birth Home Address Home Phone Number Teen Volunteer Application Summer 2016 Piedmont Medical Center 222 S. Herlong Ave. Rock Hill, SC 29732 Please Answer the Following in Complete Sentences (Attach Answers on Separate Page if Needed): -List any special activities at school, church, or elsewhere. -What previous volunteer experiences have you had? - Describe your hobbies, skills, and special interests. - How did you learn about the Piedmont Medical Center Teen Volunteer Program?
-Why do you wish to be a Teen Volunteer and why you think you should be selected for the program? (minimum 100 words) Being a Teen Volunteer means coming to volunteer once a week during the summer term. Can you make this commitment? Yes No Teen Signature: Parental Consent I hereby permit my child to join the Teen Volunteer program of Piedmont Medical Center. I understand the responsibilities of being a volunteer and the commitment required, and I will help my child to comply with the rules and regulations. Parent Name: Parent Phone Number: Parent Email Address: Name of Emergency Contact: Phone Number of Emergency Contact: Parent Signature:
Piedmont Medical Center Volunteer Auxiliary Health Screen VOLUNTEER NAME: Please provide the date you had or were vaccinated against for the following diseases: Polio DPT (diphtheria, whooping cough, tetanus) Measles (red) German Measles (rubella) Chicken Pox Mumps TB Skin Test Hepatitis Vaccination Date Had the Disease (Date(s)) Please answer the following: Are you under the care of a physician for any reason? Yes No If yes, please explain: Do you take any medication(s)? Yes No If Yes, please explain I understand that I will be required to have a TB Skin Test annually as a volunteer at Piedmont Medical Center. Yes No My personal physician is: Name: Address: Phone Number:
I understand that depending upon the level of patient contact that I have, I may be requested to provide documentation. I understand that all information concerning patient, doctor or staff member is confidential and I will not seek information regarding the same. The information provided on this application is correct to the best of my knowledge. I authorize release of information as needed from my doctor, previous hospital affiliations and/or references. Teen Signature: Guardian(s) Signature:
Teen Volunteer Program Teacher Recommendation Form To the evaluator: Participation in the Teen Volunteer program requires a high level of energy and commitment. Students must be responsible, mature, and able to work independently; therefore, we appreciate and need honest evaluations and assessments of the applicant. Students are accepted based on their application, interview, teacher recommendation, and space available in the program. Applicant s Name Teacher s Name School Phone Number Teacher s Email Please give accurate assessments. Most students will not be good or excellent in all categories. Conduct: Extent to which the student observes good standards of school conduct and obeys school regulations. Cooperation: Extent to which the student works in harmony with the class and teacher. Responsibility: Extent to which the student accepts responsibility for his/her work and behavior without shirking, evading, or blaming others. Diligence: Extent to which the student works purposely and without wasting time Attention: The student s ability to listen and follow instructions. Communication Skills: Extent to which the student speaks and writes effectively Courtesy: Extent to which the student shows respect for adults and authority, accept supervision, and treat others with kindness and tact. Excellent Good Fair Poor This student obeys rules and has not been subject to any significant disciplinary action. YES NO Teacher s Signature: