High School Student Volunteer Summer Program The Summer Student Volunteer Program, July 8, 2013 through August 16, 2013, is designed to:  

Afford high school students the opportunity to serve their community. Provide high school students the opportunity to view first-hand health related careers.

Requirements for this program are: 

Minimum age of 15 years old and completion of freshman year of high school. No exceptions.



Attend the mandatory orientation to be held at the site where you will volunteer. (Dates to be determined.)



Working papers (obtain at your high school office).



Parental consent (Under 18 years of age – see side 2 of the application).



Health Requirements: Health form (completed by your personal physician) with documentation of MMR vaccines, and two (2) Tuberculosis tests (PPD), performed by your personal physician. (This could take some time; please be certain to start this step ASAP.)



Recommendation form completed and returned to the hospital where you wish to volunteer.



Personal interview.



If you have any further questions, please contact the office of Volunteer Services at the hospital at which you would like to volunteer.

Fr. Richard Augustyn Buffalo General Medical Center 100 High Street, Buffalo, NY

[email protected]

859-2603 FAX 859-1625

MaryBeth Kupiec DeGraff Memorial Hospital 445 Tremont Street, N. Tonawanda, NY 14120

[email protected]

690-2088 FAX 690-2187

Kathy D. Gorski Millard Fillmore Suburban Hospital 1540 Maple Rd., Williamsville, NY 14221

[email protected]

568-3820 FAX 568-3832

Martha Hickey Women & Children’s Hospital of Buffalo 219 Bryant Street, Buffalo, NY 14222

[email protected]

878-7241 FAX 878-7653

Please be sure to direct all completed paperwork, phone calls or e-mails to the Volunteer Services office at the hospital of your choice and supply stamped, addressed envelopes for recommendations where necessary to ensure correct delivery. VS121-2-13

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Dear Prospective Volunteer: You have expressed an interest in becoming a Student Volunteer for KALEIDA HEALTH. It gives us pleasure to consider you for our summer program. Due to the limited number of placements at each facility, those who are chosen can be very proud. Enclosed are the following: Application Form, Recommendation Form, Consent Form, Health Screening Form and Work Schedule for you to complete. The following checklist is prepared for your convenience: 

Complete application form.



Recommendation: Take the recommendation form with a stamped, addressed envelope immediately to the person recommending you. This can be from a personal, school or work source. Check shortly thereafter to be sure it has been sent to the appropriate address and site at which you want to volunteer.



Personal Interview. All interviews will occur prior to May 7, 2013. Notification of acceptance to the program will be issued the first week in June. It is your responsibility to schedule a personal interview at the site at which you wish to volunteer. Your application should be sent to the site prior to the interview. The balance of your paperwork will be processed if you are accepted into the program.



Working Papers (Copy required): Applications for working papers are available in your school office.



The health screening form must be completed by your personal physician with documentation of MMR and two-step PPD. PPD needs to be current (i.e., performed within the last year). • •



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Unless all forms are completed, you will not be able to participate in the Student Volunteer Program. Clearance from our Employee Health Office is required prior to beginning your service.

Attend the mandatory orientation at your site. You will be notified of the date and time if accepted into the program.

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Check one:

   

Buffalo General Medical Center DeGraff Memorial Hospital Millard Fillmore Suburban Hospital Women & Children’s Hospital of Buffalo

Application for Student Volunteer Summer Program (Please print clearly) Name

Date of Birth Last

First

Number

Street

Age

Middle

Address

Soc. Security # Telephone, Home City

State

P

Zip code

Telephone, Cell

E

E-Mail Father Work Phone Father Cell Phone Mother Work Phone Mother Cell Phone

Father’s Name/Occupation Mother’s Name/Occupation School Grade

R S O N

Work/Volunteer Experience Career Interests

A

Hobbies/Special Interests/Skills

L Have you ever been convicted of a crime?

 Yes  No

Is volunteer work a requirement for school credit?

If yes, explain when, where, and disposition of case.

If so, number of hours required.

Requirements:  Minimum age of 15 years and completion of the freshman year of high school. No exceptions.  Attend the mandatory orientation at your site.  Working papers – copy required (under 18 years of age).  Parental consent (under 18 years of age—see page #2 of application).  Health form (completed by your personal physician) with documentation of MMR vaccines, and two (2) Tuberculosis tests (PPD), performed by your personal physician. (This could take some time; please be certain to start this step ASAP.)  Written recommendation  Interview VS121-2-13

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R E Q U I R E M E N T S

Name

Student Volunteer Summer Program Application (continued) Physical and Medical Background Do you have any physical condition or medical problem which may limit your ability to perform the work of a volunteer?

 Yes

 No

If “YES” please explain.

In case of an emergency, please notify: Name Relationship Phone

Parental Consent I give consent to my child’s participation in the Kaleida Health Student Volunteer Program. I authorize KALEIDA HEALTH to give emergency medical treatment to my son / daughter. I understand that I am also consenting to the administration of an intradermal tuberculin skin test (if needed) as required by NYS Dept. of Health (PPD). I agree that the above information is correct as of the date it has been filed. Signature of Parent or Guardian

Date

I agree and will follow the rules, regulations and policies of the Volunteer Department and of KALEIDA HEALTH.

Signature of Applicant

Date *** For Office Use Only ***

Date Received

Volunteer Number

Training

Interview Date and Time

Department

Day/Time

TB Test Taken

Picture Taken

RECOMMENDATION FORM This form is a requirement for students to be considered for volunteer placement. Student: Please provide a stamped, addressed envelope for this purpose to the person recommending you. Please complete and send this form directly to the Volunteer Services Department at the hospital indicated by the applicant. Thank you for your invaluable help in selecting suitable candidates for this community hospital program. Please mail this form directly to the hospital in the envelope provided by the applicant. The deadline is May 17, 2013. Please be certain to sign this form and list your telephone number should we wish to contact you. 1.

Name of applicant.

2.

How long have you known this applicant?

3.

Does the applicant have the willingness to learn and then follow through and do a job thoroughly?



Yes



No

4.

Is he/she apt to drop out of the program before its completion?



Yes



No

5.

Is the applicant responsible and dependable?



Yes



No

6.

Can he/she work independently?



Yes



No

7.

Does he/she have a good attitude toward the community which will be reflected within the hospital?



Yes



No

Do you think this applicant will be an asset to the Student Volunteer Program, offering his/her service to help others while learning about hospital careers?



Yes



No

8.

Please feel free to share some personal comments:

Signature

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Telephone No.

High School Student Volunteer Work Schedule (Please print clearly.) Name: Age:

Address:

city

Phone Home

state

zip

E-mail

Cell

Please discuss this schedule with your parents and consider your transportation needs and work schedule BEFORE completing this form. Please indicate with a check mark (  ) 3 of the days(s)/times when you may be available. Please, also, confirm with your parent/guardian that you have transportation. Time

Sun.

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

a.m.

a.m.

a.m.

a.m.

a.m.

a.m.

a.m.

p.m.

p.m.

p.m.

p.m.

p.m.

p.m.

p.m.

8:00 a.m. - 12:00 p.m. 12:00 p.m. -

4:00 p.m.

4:00 p.m. -

8:00 p.m.

Will you be taking Driver Ed?  Yes  No

(SHIFT TIMES MAY VARY BY SITE) Will you be attending summer school?



Yes



No

Will you have a summer job?



Yes



No

Please check the areas of service you are interested in: 

Nursing



Emergency Department (liaison, greeter)



Physical Therapy



Offices (clerical)



Surgical Care Unit



Pharmacy



Reception / Greeter



Errands/Escorts



G.I. (gastrointestinal)



Other

Your commitment of time and effort represents a vital part of the hospital program.

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Employee Health Department Volunteer Physical Examination Form New York State Department of Health requires the following to medically clear you to volunteer at a hospital: Physical, 2 step PPD, proof of immunization/immunity to Rubella, Rubeola, and Varicella. Name: _____________________________________________________SS#: ______________________

Sex:  M

 F

DOB: ___________________

Address: ___________________________________________________________________________Phone #: ____________________________________________ Applicant must complete infectious disease history.

History of any of the following : Measles German Measles Chicken Pox Mumps Tuberculosis Hepatitis Yellow Jaundice Polio Herpes Simplex (oral or hand)

Yes

IMMUNIZATION HISTORY (VACCINES) To be completed by physician.

No

Indicate the approx. dates of the following:

Date (s)

Diphtheria/Tetanus/T dap Hepatitis B Vaccine: yes / no #1: #2: #3: Rubeola Vaccine (or positive titer) (2 Doses required) # 1: #2 Rubella Vaccine (or positive titer) (1 Dose required) #1: Varicella Vaccine (or positive titer) #1 #2: PPD/TB Skin Test (2 PPD’s administered in past 12mos.) PPD#1 Date Placed Date Read: Results in mm: PPD#2 Date Placed Date Read: Results in mm: If known history of positive PPD, provide date of conversion and last chest x-ray:  Asymptotic-denies all symptoms  Symptomatic-fatigue, Anorexia, Weight loss, Low grade fever, Productive cough (circle any that

pertain) List any medications (over the counter or prescribed by a physician): ____________________________________________________________________________ APPLICANT PLEASE COMPLETE Now

ANSWER Past

COMMENTS (to be completed by physician) Never

ALLERGIES (Latex, Medications, etc) CHRONIC COUGH (more than 3 weeks) ASTHMA HEART TROUBLE (chest pain, heart attack, etc) HERNIA NECK/BACK INJURY OR PAIN ARTHRITIS WEAKENED IMMUNE SYSTEM (such as leukemia, HIV+, chronic steroid use, chemotherapy) FAINTING SPELLS SEIZURES SKIN PROBLEMS DIABETES SHORTNESS OF BREATH CHEST PAIN HEARING PROBLEMS VISION PROBLEMS ILLEGAL DRUG USE MAJOR ILLNESSES/HOSPITALIZATIONS MENTAL HEALTH CONDITIONS DO YOU DRINK ALCOHOL DO YOU SMOKE

*** To be completed by physician *** Normal SKIN EYES EARS NOSE MOUTH/THROAT NECK , THYROID LYMPH NODES CHEST HEART ABDOMEN BACK NEURO EXTREMITIES HERNIA

Abnormal

Provider: please comment on abnormalities

Vision Uncorrected Corrected

Distance 20/ 20/

Near 20/ 20/

Blood Pressure : Pulse : Height

Weight

General Appearance:  Good  Fair

 None

 Poor

 Present

PLEASE OUTLINE ANY LIMITATIONS: _____________________________________________ MEDICALLY RELEASED TO BEGIN VOLUNTEERING ON: _

_/_ ___/

__

NP/PA/PHYSICIAN SIGNATURE: ________________________________DATE: ________________________ VS121-2-13

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