TEEN VOLUNTEER APPLICATION (AGES 16-17) APPLICATION MUST BE FILLED OUT BY THE INDIVIDIAL APPLYING FOR THE VOLUNTEER POSITION. Completed applications can be returned to Lake Wales Medical Center Dir. Volunteer Services, Julie Sing, 2 nd Floor Hunt Building, Office 200. All applications must be accompanied by a letter of recommendation. Please note that completing a volunteer application does not guarantee the admission to the volunteer program at LWMC. Placement depends on availability and all prospects must pass an interview, drug screening, and Tuberculosis test before being admitted to the program. Thank you for your interest in becoming a Volunteer at Lake Wales Medical Center! PERSONAL INFORMATION First Middle Last Parent or Guardian name(s): of Birth Social Security # Driver s License # Email address Mailing address City State Zip Phone Secondary Phone Age EMERGENCY INFORMATION Emergency Contact Relationship to you Home Phone Work Phone Cell Phone Do you have any relatives or friends employed by or volunteering at this hospital? Name Position Relationship 1
QUESTIONNAIRE Do you have any physical conditions, which may limit your activities/abilities to perform any of the various volunteer jobs? Yes [ ] No [ ] If yes, please explain Special interests/hobbies/skills: What are your career ambitions? _ EDUCATION/COMMUNITY INVOLVEMENT/WORK EXPERIENCE School: Grade: Courses currently taking, school activities, clubs, honors, etc. Do you have plans to continue your education after high school? If yes, what course of study do you want to pursue? List any community affiliations (church, civic groups, etc.) Are you seeking volunteer work as a requirement for graduation or for scholarships? If yes, please explain: Have you ever volunteered in the past? If yes, describe where and what you did: Briefly explain why you want to join our Teen Volunteer Program: 2
Please check all areas that you are interested in working in the hospital: Please note that area is BOLD are where we typically have the most need. [ ] Emergency Department [ ] Lobby Information Desk [ ] Marketing (Assemble Welcome Cups) [ ] Materials Management (Stocking) [ ] Medical Records [ ] Physician Offices (filing) [ ] Other: Please note that some areas of volunteering can only accommodate certain time frames, and those time frames may not work with a teen s school schedule. When can you start volunteering? How many hours do you plan to volunteer (total)? Please mark days and times you are available to volunteer. Note: Volunteers typically work 1 or 2 shifts each week. [ ] Monday to [ ] Tuesday to [ ] Wednesday to [ ] Thursday to [ ] Friday to [ ] Saturday to [ ] Sunday to 3
PARENTAL/GUARDIAN SIGNATURE I hereby permit my son/daughter/charge to participate in the Teen Volunteer Program at Lake Wales Medical Center. I also give permission for a drug test to be completed on my son/daughter/charge for participation in this program and understand that I will be informed if the test is positive. I further release the hospital from any legal or other responsibilities for any injuries, act, or incidents involving the volunteer. Parent/Guardian Signature Phone Numbers TEEN VOLUNTEER APPLICANT SIGNATURE I hereby submit my application and letter of recommendation for the Teen Volunteer Program at Lake Wales Medical Center. I agree to a drug test for participation in this program and understand that a positive test results will be provided to my parent/guardian. I understand that the Volunteer Manager makes all regular assignments, based on a personal interview and the interests of each prospective teen volunteer. I agree to abide by the policies and procedures of the Volunteer Services Department. Confidentiality Agreement: I understand and agree that, in the performance of my duties as a teen volunteer, I must hold patient / medical information in confidence. Information should not be discussed with any individuals including co-workers, other volunteers or family. I also understand that any violation of patient confidentiality will result in termination from the volunteer program. Teen Signature Phone Number 4
CERTIFICATION AND AUTHORIZATION FOR VOLUNTEERS (Please read the following paragraph carefully before signing) I certify that the information that I have provided is true and correct to the best of my knowledge and belief. I authorize Community Health Systems (the "Company") to investigate my employment and personal history, including an inquiry concerning information on my criminal, credit and driving history, if appropriate. In connection with this investigation, I authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies and former employees to release information they may have about me and release them from any liability or responsibility from doing so. This authorization, in original or copy form, shall be valid for this and any future investigation conducted by the Company. I am aware that if I am denied employment based on a report by a consumer-reporting agency, the Company will furnish the name and address of such agency upon my written request. Print legal first, middle and last name Social Security Number (Required) DOB Driver s License # & State Issued Street Address City, State, Zip Volunteer Signature Teen Parent/Guardian Signature 5