Dear Volunteen Applicant: Thank you for your interest in volunteering at Marian Regional Medical Center. Our Volunteen Program is for current high school students who are at least 14 years old. Please carefully review the enclosed application materials and general information regarding volunteering at our hospital. As a volunteen, you will have the opportunity to join a team of volunteers dedicated to highquality patient care. Employees and volunteers at Marian are committed to providing services to patients in a caring and respectful manner. We honor the individual worth and dignity of each patient and their family members. Volunteering can be an enjoyable experience, but it is also a serious commitment. To be accepted as a volunteen, we require that you maintain a regular schedule throughout the program. We encourage your commitment so that we can provide you with a meaningful volunteer experience. Once you have completed the enclosed application and forms, please return them to the Volunteer Services Office. Your application will be reviewed and a Volunteer Services representative will call you to set up an interview with you and a parent. The application deadline is Friday April 27, 2018 and only completed applications (with current vaccination records) will be accepted. Slots for interviews and volunteering positions are awarded on a first-come, first-served basis, so please turn in your application early. In addition, due to the popularity of the Volunteen Program, a waitlist may need to be created. If a wait list is needed, volunteens will be contacted when openings become available. We look forward to sharing opportunities with you and welcoming you to our team of health care professionals dedicated to improving the quality of life and health of the people we serve. Please feel free to contact the Volunteer Services office at (805) 739-3520. Sincerely, Tim Rohan, RN, MSN, CEN, CFRN Service Area Director Patient Care Services Administration
For Office Use Only: Application Rec d: i/a o/a Time With PERSONAL INFORMATION Name Last First Middle Social Security No. (must include) Address Street & No. Apt. # City/Town State Zip Home Telephone No. Work Telephone No. Cell Phone No. Date of Birth: Email: Are you 18 years of age or older? YESNO If you are under 18, your parent or guardian s signature is required. See page 3. Have you ever volunteered at Marian Regional Medical Center? When? What Department? Why did you leave? YESNO IN CASE OF EMERGENCY, WHOM SHOULD WE CONTACT? Name: Relationship: Phone ( ) Day(s) you are available to volunteer? (circle) TELL US ABOUT YOURSELF What area are you most interested in? (circle) M T W TH F SA SU Direct Care/Patient Contact Administrative/Clerical What population would you like to work with? (circle) Time(s) you are available: What departments or programs are you most interested in? Children Teens Adults Seniors No Preference Do you speak another language? YES NO If yes, what language? Have you ever been convicted of a crime (s), misdemeanor (s) or felony? YES NO If yes please give date (s) and details: How did you learn about Marian s Volunteer Program? Do you have any physical, mental or medical condition, which would limit your ability to perform functions of a volunteer job? YES NO If yes, please describe: Please note: Disclosure of a criminal record will not automatically disqualify you from volunteer consideration. Additionally, falsification or omission of information on this application may result in immediate dismissal. Are you volunteering for the summer only? YESNO Please Go To Next Page.
EMPLOYMENT OR VOLUNTEER EXPERIENCE INFORMATION Please list any work and/or volunteer position(s) you have held. Include company/institution and supervisor s name. Please list most current positions first. If you have never worked or volunteered in past, please go to the next section. Employer/Volunteer Org. From To Position and Duties Reason for leaving Company or Organization Name Position: Address City and State: Duties: Name and Title of Supervisor Telephone: May we contact him/her? YESNO Employer/Volunteer Org. From To Position and Duties Reason for leaving Company or Organization Name Position: Address City and State: Duties: Name and Title of Supervisor Telephone: May we contact him/her? YESNO *If you have never worked or volunteered please list one academic or non-personal reference (i.e. teacher, guidance counselor, pastor, rabbi, etc.): Name: Relationship (i.e. teacher, pastor, etc.): Phone Number: *Your reference cannot be someone you are related to. EDUCATION INFORMATION If you are currently in high school, please tell us what school do you attend? What grade are you in? Major/Concentration: School Location: What college or university do or did you attend? Major: School Location: Did you graduate? YESNO Graduation Date: GPA What is your average (i.e. A, 3.0, 85%, etc.)? Other schooling, certifications or licenses? School: Certification, License or Degree: School: Certification, License or Degree Degree completed: Please Go To Next Page.
PERSONAL STATEMENT In a brief paragraph please describe why you are interested in volunteering at Marian Regional Medical Center: I have answered each question fully and correctly. I understand that any deliberate misstatement will disqualify me, or will cause immediate termination of my volunteer assignment. I authorize Marian Regional Medical Center Volunteer Services Department to fully investigate my references. I understand that in accordance with Marian Regional Medical Center, volunteer placement is conditional upon satisfactory clearance by the criminal background check. I hereby agree that I will keep confidential all materials I may read or learn about during my work here as a volunteer. In this regard, I will only discuss this information with appropriate staff and will never, under any circumstances, reveal the name of a patient.. Signature: Date: If under 18, Parent/Guardian Signature required: Parent Signature Date: http://www.marianmedicalcenter.org/volunteer_information *PLEASE NOTE THAT THIS APPLICATION MUST BE THOROUGHLY COMPLETED.*
MARIAN VOLUNTEEN PROGRAM Immunization History NAME: MMR Vaccine #1........................................... Date: MMR Vaccine #2........................................... Date: Chicken Pox Vaccine #1...................................... Date: Chicken Pox Vaccine #2...................................... Date: OR Chicken Pox disease verified in writing by MD, with copy attached Date of Verification:............. Yes No Copies of all immunization records attached?...................... Yes No You must attach a copy of your immunization records to this form. TB Screening Test Parental Consent In compliance with regulatory requirements and hospital policy, Volunteens are required to have a TB Screening Test in the form of a blood draw in order to participate in the Program. The hospital has arranged for the Laboratory Services Department of Marian Regional Medical Center to administer this test. By signing this form I, as parent/guardian of this student, am authorizing the Marian Regional Medical Center Laboratory Services Department representative to administer this test. has my permission to receive the TB Screening Blood Draw test from the staff of Laboratory Services of Marian Regional Medical Center. Parent Signature: Print Name: Date: Student Signature: Print Name: Address: City/State/Zip: Phone:_
Marian Regional Medical Center Volunteer Services VOLUNTEEN PROGRAM NAME OF APPLICANT: AGE: REFERENCE (Teacher, Counselor, Pastor, Coach) The above-named student is applying to be a Marian Regional Medical Center volunteen. In compliance with The Joint Commission and Dignity Health, each student is required to have a reference to become a volunteen. If you recommend this teen for the program, please fill out the form below. Date: Position: Employed by: (Print Name) (Signature) (Your Address) (City/State/Zip) (Daytime Phone) Please describe why you would recommend this teen for this program
VOLUNTEEN PROGRAM ELIGIBILITY AND REQUIREMENTS The following items must be met in order to participate in our volunteen program. Please review them carefully. 1. Volunteer services are donated to Marian Regional Medical Center without contemplation of compensation or future employment and are given for humanitarian or charitable reasons. 2. You must be able to maintain a regular schedule for the entire Program (Summer or School Year). 3. We will provide, at your request, a report of your hours for school or any other community service requirement. A minimum of two (2) business days notice is required for Volunteer Services staff to generate the report. 4. Volunteers must have the ability to keep patient information, conversations, and observations confidential. 5. Volunteers must demonstrate willingness to help staff, patients, visitors, physicians and other volunteers whenever possible. 6. Volunteers must have the ability to use good judgment in unusual circumstances. 7. Volunteers must have good communication skills to be able to communicate with patients, visitors, staff and supervisors. Volunteers in all areas must be able to communicate in a clear, understandable, and courteous manner. 8. Volunteers must be able to speak, read and write in English (knowledge of a second language is a plus). 9. Volunteers must be reliable. If you are unable to come for your shift, you are required to call the Volunteer Office. 10. If you are unable to continue volunteering, notify the Volunteer Office. 11. All volunteer applicants must demonstrate an appropriate and positive manner of behavior and communications skills with all persons at all times, including guests, staff, vendors, and other volunteers. 12. If you are involved in a sport, please notify us in advance, so we can work with your schedule. 13. Volunteers work under the direction and supervision of paid staff and do not earn or collect a salary from the hospital, or department, where they volunteer. Volunteers are not to accept tips or gifts from patients and visitors. 14. You must come for an interview with the Volunteen Program Director before attending orientation. A parent or guardian must accompany you for the interview. 15. You must attend the general orientation presented by the volunteer department before you begin volunteering. 16. You must be dependable, honest, and willing to take direction to perform assigned volunteer duties.
17. You must obtain a recommendation from someone who has knowledge of your work skills, academic achievements or community service and is not a relative. 18. You must be in good general health. All volunteers must have a TB test and flu shot annually. 19. You will be required to wear a volunteer uniform. The uniform consists of a volunteer polo shirt or smock to be purchased from the Volunteer Office for $20, worn with your own white, black or khaki pants. Shoes must be closed toe. All items of clothing and shoes must be neat and clean. Jeans of any color, Capri or cropped pants, and shorts are not permitted as part of the uniform. 20. A small amount of jewelry may be worn, for example, a wristwatch, ring, and small pair of earrings. Large hoops or long dangling earrings, heavy chains, are not permitted. 21. Hats, caps, bandanas may not be worn as part of the uniform. 22. You will be issued a photo identification badge at the beginning of your volunteer service. The badge must be worn above the waist, attached to the collar of your volunteer shirt or to an ID rope or chain, and must be visible at all times while you are on volunteer duty. The badge is Marian property and must be returned upon termination of volunteering. The above requirements must be met in order to participate in the volunteen program at Marian Regional Medical Center. Applicants who do not comply with these requirements, or who return incomplete information, will not be invited to participate. Additionally, your status as Volunteer may be terminated at any time if you fail to follow the policies and procedures of Marian, and those of the Department of Volunteer Services. You may also be dismissed for absence without notice, for unsatisfactory attitude, poor work habits, or appearance, and any other circumstances, which could be harmful to the best interests of Marian and/or the volunteer program. Signature of Applicant Date: Signature of Parent/Guardian Date:
Absence Policy Acknowledgement Form Marian Volunteer Services exists to meet the service needs of Marian Regional Medical Center. Our mission is accomplished through the dedicated support and service of our many wonderful volunteers, who are an important part of our health care team. Because we strive to serve the patients, families, and staff at Marian effectively and committedly, your presence is essential. PLEASE REVIEW, SIGN and RETURN the revised absence policy, as it will be effective immediately: EXCUSED ABSENCES: Volunteens are allowed three (3) excused absences for the school year. Excused absences: Prior to the shift, the teen s parent/guardian notifies the volunteer office that a shift will be missed. After 3 excused absences, the Volunteen will receive a warning letter and dismissed if a 4 th absence occurs. PLANNED ABSENCES: Please inform the Volunteer Office and complete the absence form if you have a planned absence. UNEXCUSED ABSENCES: This is a no call and a no show situation. If a Volunteen misses 2 shifts, without notifying the Volunteer Office, he/she will be sent a warning letter and dismissed if a 3 rd unexcused absence should occur. TARDIES: If a Volunteen will be late for a shift, the Volunteer Office should be contacted. Otherwise, we will assume the Volunteen is absent without contacting the Volunteer Office. Thank you for your understanding regarding our policy. We are striving to provide the best care possible for our families and patients, and the commitment of every volunteer is vital to that goal. -Volunteer Services Office Please sign below, indicating your compliance with our revised absence policy. I acknowledge that I understand and will comply with the Marian Volunteer Services absence policy and understand that it represents the policy of the Department. If I have any questions about the policy, I may contact the Volunteer Services Office at 805.739.3520. Volunteen Name (Printed) Signature of Volunteen Signature of Parent/Guardian Date: Date:
Dear Marian Volunteen and Parents: Cell Phone Policy Acknowledgement Form Marian Volunteer Services exists to meet the service needs of Marian Regional Medical Center. Our mission is accomplished through the dedicated support and service of our many wonderful volunteers, who are an important part of our health care team. Because we always want to create a positive impression and because service is our first priority, our office would like to remind you that cell phone use is not allowed while volunteers are on duty. By creating a negative first impression for our patients, visitors, and families, this violates our Core Service of Dignity and can be a distraction for the volunteer from service. The first time a volunteer is caught using a cell phone, he/she will be given a conduct notice to be signed by the teen s parent(s) and returned to the volunteer office by their next shift. The second time a volunteer is caught using a cell phone, he/she will be excused from further participation in the Volunteen Program. If the volunteer has a cell phone during his/her shift, the phone should be stored in the volunteer s bag and set to silent with all notifications turned off. Thank you for your understanding regarding our policy. We are striving to provide the best care possible for our families and patients, and making sure that cell phones are not a distraction for our volunteers will be a great help in this. -Volunteer Services Office Please sign below, indicating your compliance with our cell-phone usage policy. I acknowledge that I understand and will comply with the Marian Volunteer Services cell phone usage policy and understand that it represents the policy of the Department. If I have any questions about the policy, I may contact the Volunteer Services Office at 805.739.3520. Volunteen Name (Printed) Signature of Volunteen Date: Signature of Parent/Guardian Date: