ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: Elizabeth Seton Pediatric Center Volunteer Application Package

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ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: Elizabeth Seton Pediatric Center Volunteer Application Package

Volunteer Application Package Instructions Thank you for your willingness to volunteer with Elizabeth Seton Pediatric Center. To ensure the safety of our residents and staff, all individuals must go through the volunteer application process and be approved before beginning a volunteer assignment. The application process includes a background check through our vendor. Please complete the Volunteer Application Package in its entirety. Please ensure that all signatures fields are signed in this package. Please Do NOT staple forms when submitting them! Please send forms Except the Medical Papers directly to: Elizabeth Seton Pediatric Center Vanessa Andrews Volunteer Services 300 Corporate Blvd. South Yonkers, NY 10701 vandrews@setonpediatric.org To successfully complete the Volunteer Application Package, please follow these instructions: 1. Print out the volunteer application packet Complete all of the required information and signatures. Include your email address in order to receive notification of approval. 2. Attach a copy of your driver s license or other legal photo identification to your application. The application requires a copy of your driver s license or other photo ID that includes your legal name, date of birth, height and weight. This helps to verify your identity in the background check process. Please complete all information on the background check forms. 3. Medical Examination Form. Please complete its entirety and submit all questions or communication regarding medical requirements to the Employee Health Nurse. Shauna Beharie, RN Elizabeth Seton Pediatric Center 300 Corporate Blvd. South Yonkers, NY 10701 Phone: 914-294-6321 Fax: 914-294-6345 Sbeharie@setonpediatric.org 4. Volunteer Reference Questionnaire. You will need to provide three (3) references. This form should be given to a Professional/Educator to whom you are not related. The individual reference should complete the form and return it to Elizabeth Seton Pediatric Center, Attention: Vanessa Andrews. Please use the attached reference questionnaire document and make copies for your references.

ELIZABETH SETON PEDIATRIC CENTER VOLUNTEER APPLICATION Date: PERSONAL INFORMATION (PLEASE PRINT) Name (Last, First, MI) Social Security Number Address Apt. # Email City State Zip Code Telephone ( ) Emergency Contact Emergency Telephone ( ) Have you ever been convicted of a crime? Yes No Are any criminal charges pending against you? Yes No If yes, explain fully, Have you been convicted of child abuse? Yes No Are any charges of abuse, neglect or maltreatment of a child currently pending against you? Yes No If Yes, explain fully, How were you referred to Elizabeth Seton Pediatric Center? Referred by Center for Pediatric Employee Name Relationship to you School Name Internet Newspaper Ad Other ACADEMIC BACKGROUND School (High School or College): Dates Attended: From to Address City State Zip Code Status (freshman, sophomore, junior, senior, graduate): Major: Graduation Date: Degree Earned/Sought: School (High School or College): GPA: Dates Attended: From to Address City State Zip Code Status (freshman, sophomore, junior, senior, graduate): Major: Graduation Date: Degree Earned/Sought: GPA: PREVIOUS VOLUNTEER HISTORY Agency Name: Telephone ( ) Address City State Zip Code Type of Service: Days Volunteered: Interests or special skills you would like to share:

What are your learning objectives for this placement and in what way will this experience allow you to accomplish these objectives? List any language (other than English) that you speak fluently: Days & Time Available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Volunteer work preferences: Clerical Skills (Typing, filing, phone receptionist, etc.) Patient Care Services as applicable to organization (Reading to patients, companionship, etc.) Personal Skills to Use or Teach: (Drawing, painting, crafts, gardening, etc.) Additional Skills: REFERENCES List 2 Business/School and Personal Name and Address (Include City & State) Occupation Telephone Number Company I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to termination of volunteer from the Elizabeth Seton Pediatric Center whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Student s Signature: Date: Note: Please send attached reference forms with letter to your 3 references and ask them to forward the references directly to: Elizabeth Seton Pediatric Center Vanessa Andrews Volunteer Services 300 Corporate Blvd. South Yonkers, NY 10701 vandrews@setonpediatric.org Please DO NOT Staple

ELIZABETH SETON PEDIATRIC CENTER APPLICANT MEDICAL FORM Instructions: Please complete page 2. Your physical exam (page 3) will need to be completed by a physician or nurse practitioner. Your completed forms need to be accompanied by your immunization records OR a copy of titers (a blood draw showing that you have the immunities that you would have received as a result of immunizations). The following immunizations are required: Measles Mumps 2 doses of live vaccine Rubella Varicella (chicken pox) 2 doses or titers proving that you have had the illness Tetanus (latest booster within last 10 years) DTaP, DT, Tdap, or Tp are acceptable Hepatitis B 3 doses Flu (during Flu season October through May) Proof of one negative PPD is required (given in the last 6 months). If you have had a positive PPD then your test results must be accompanied by a negative chest x-ray. We will administer the second PPD on your first day of internship. Please mail/fax this form along with your proof of immunizations directly to the employee health nurse: Shauna Beharie, RN Elizabeth Seton Pediatric Center 300 Corporate Blvd. South Yonkers, NY 10701 Phone: (914) 294-6321 Fax: (914) 294-6345 All questions or communication regarding medical requirements should be made directly to the employee health nurse. Page 1 of 3

MEDICAL HISTORY Completed by Applicant Name Date of Birth Address City State Zip Telephone # Email Address Job Title Emergency Contact Person Emergency Phone # PAST HISTORY Have you had any of the following? (INDICATE Y FOR YES, N FOR NO) Asthma Depression Hepatitis Thyroid Disease Arthritis Eczema High Blood Pressure Tuberculosis Bronchitis Epilepsy / Seizures Immune Disease Ulcers Cancer Fainting/Dizziness Kidney Disease Varicose Veins Chronic Cough Heart Disease Pneumonia Other: Colitis Headaches Rheumatic Fever Diabetes Hemorrhoids Shortness of Breath Have you had any hospitalization or surgery? (List Dates, Diagnoses) What medications are you taking? (List Name of Drug, Dosage, and Frequency. Include EPI PEN in this list) Do you have allergies to: (Medications, Foods, Latex, Insect Stings, or Etc.) Please list all: Do you/ Did you use Tobacco? YES NO IF YES, ( # packs / day x # yrs) How often do you drink alcoholic beverages? ( #drinks / day / wk / month) FAMILY MEDICAL HISTORY: (Cancer, Diabetes, Heart Disease, High Blood Pressure, other) MOTHER: FATHER: SIBLING: GRANDPARENT: SYSTEM REVIEW (Check the box) Neuro: Headache Dizziness Seizures Visual Problems Chest: Pain Palpitations SOB Cough Blood in Sputum GI: Stomach Ache Rectal Pain Blood Constipation Diarrhea GU: Pain on Urination Frequency on Urination Blood in Urine Musculoskeletal: Joint Pain Back Problems Deformities Menstruation: Regular Irregular Menopause LMP Last Pap Test Mammogram Breast Self-Exam Comments: I certify that I am free from a health impairment that would present a risk to the residents or which might interfere with the performance of my duties. I further certify that I am free from habit or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances that might alter my behavior. I hereby certify that all statements and answers provided by me on this examination form are complete and true to the best of my knowledge. I understand and agree that my appointment to the Pediatric Center is conditional upon full disclosure of all medical information and the failure to do so shall constitute grounds for immediate termination of employment. Signature Print Name Date Page 2 of 3

ELIZABETH SETON PEDIATRIC CENTER PHYSICAL EXAMINATION (Completed by Physician) VITAL SIGNS: T P R BP HT WT General Appearance: Skin: HEENT: Spine: Lungs: Heart: Abdomen: Extremities: Neurological: REQUIRED VACCINATIONS AND TITERS: IMMUNIZATION DATE ADMINISTERED TITERS TITERS MEASURED Varicella Rubella Measles Mumps TDAP PPD# 1 Date Planted: Site: Lot #: Exp. Date: Date Read: mm: Negative: Positive: CHEST X- RAY (If positive PPD results) Date: Negative: Positive: RECOMMENDED IMMUNIZATION DATES: Hep B 1. 2. 3. Influenza Signature of Examiner Date Review & Complete (Initials) PPD #2 (Can be provided by ESPC after initial visit) PPD# 1 Date Planted: Site: Lot #: Exp. Date: Date Read: mm: Negative: Positive: Signature of Examiner Date Page 3 of 3

VOLUNTEER REFERENCE QUESTIONAIRE Applicant Name: TO THE VOLUNTEER APPLICANT: This form should be given to a Professional/Educational to whom you are not related. The individual reference should complete the form and return it to Elizabeth Seton Pediatric Center. TO THE REFERENCE: The person name above is applying to become a volunteer at Elizabeth Seton Pediatric Center. Please complete this questionnaire and return it to ESPC via email, Attention: Elizabeth Seton Pediatric Center Vanessa Andrews 300 Corporate Blvd. South Yonkers, NY 10701 vandrews@setonpediatric.org Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner?

How was the applicant s verbal and written communication? Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _

Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner? How was the applicant s verbal and written communication?

Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _

Please TYPE or PRINT clearly Reference Name: Organization: Title: Phone: Position Information I. What was your relationship with the applicant? (This includes the nature of the reporting relationship, length of time, etc.) Please confirm the applicant s Title: Primary area of responsibility: Professional Information I. Please comment on the applicant s overall performance Strengths: I How well does the applicant follow instructions? Did the applicant complete assignments in a timely manner? How was the applicant s verbal and written communication?

Areas of Further Development I. In order for the applicant to continue to grow professionally, can you give me examples of a couple of areas where he/she could continue to develop? Additional Questions I. How well did the applicant get along with his/ her co-workers or colleague? Did the applicant have any problems with lateness or absenteeism? I Did the applicant have any disciplinary problems? IV. If you had the opportunity to work with the applicant again, would you? _

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