Mission Hospital Junior Volunteer Application Packet
We are delighted that you are interested in joining the Junior Volunteer Program at Mission Hospital. The Junior Volunteer Program exists to provide excellent service to our patients, their families and hospital staff. It will also introduce you to many opportunities in a professional work environment. Our hope is that Junior Volunteers can assist us with our goal of service while also learning about future career opportunities. Attached you will find an Application, two Reference Forms and a Vaccination Questionnaire. Please fill out the Application completely and make sure that you and your parent/guardian have signed the form. Your Reference Forms must be filled out by two current teachers in the 2010-2011 School Year. *Please note that references may not be completed by anyone who is related to you. There are a limited number of spaces for the Junior Volunteer Program and applicants will be considered in the order that all completed paperwork is received in our office. Complete applications will include the Application Form, two Reference Inquiry Forms, Vaccination Questionnaire and Immunization Records. The deadline for submitting paperwork for the Summer 2011 Junior Volunteer Program is Friday, March 4 th. However, the program will likely be full prior to the deadline. All paperwork should be submitted to: Mission Hospital Volunteer Services 509 Biltmore Avenue Asheville, NC 28801 Fax: 828-213-4151 Please call the Volunteer Office at 213-4187 if you have any questions. We look forward to working with you.
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
Mission Hospital Junior Volunteer Application Packet APPLICATION FORM
Date _______________ Name ____________________________________________________________________________________________________________ (Last) (First) (Middle) Mailing Address ________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Home Phone
_______________________________
Cell Phone _____________________________________________
Email Address __________________________________________________________________________________________________ Date of Birth________________
Age_________
Year of High School Graduation ______________
School______________________________________________________ APPLICANT’S STATEMENT: In your own words, tell us briefly why you want to be a volunteer at Mission Hospital. You may attach additional pages as necessary. _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
Mission Hospital Junior Volunteer Application Packet
PARENT/GUARDIAN INFORMATION 1. Name Address
_________________________________ _________________________________ _________________________________
Home phone ___________________ Work phone ___________________ Cell phone ___________________
2. Name Address
_________________________________ _________________________________ _________________________________
Home phone ___________________ Work phone ___________________ Cell phone ___________________
In case of emergency notify parent or guardian listed above or: Name Phone
________________________________ ________________________________
Relationship: ____________________
APPLICANT AGREEMENT I hereby certify that the answers on this application and any resultant interviews are true and correct, and that misrepresentations or omission of facts, misleading or false information on my part will be grounds for dismissal as a volunteer. Acceptance as a volunteer is contingent upon satisfactory references and verification of the information submitted on this application. I, therefore, authorize you to make such investigations and inquiries as you deem necessary in arriving at a decision. I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer services herein applied for, and Mission Hospital Volunteer Services is not obligated to assign or actively seek to assign volunteer services for me. I authorize that all employers, schools, or references thus contacted be released from all liability in answering inquiries related to my application. _______________________________________________ Applicant Signature
________________________ Date
_______________________________________________ Parent/Guardian Signature
________________________ Date
Opportunities for volunteers are provided without regard to race, color, gender, religion, age national origin, sexual orientation, disability or age. Junior Volunteers must meet minimum age requirement of 14 years of age.
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
Mission Hospital Junior Volunteer Application Packet Junior Volunteer Reference Inquiry The student named below has applied to the Junior Volunteer Program at Mission Hospital and has requested that you provide a reference for him/her. This form should only be filled out by a current teacher. A reference completed by a teacher who is related to the applicant will not be accepted. Please remember that Mission Hospital is an acute care facility and that Junior Volunteers will interact with patients, families and hospital staff. Return this form at your earliest convenience. We cannot proceed with the application process until all reference forms are received. APPLICANT________________________________________________________________________________________________________________ Please check the appropriate spaces: PERSONAL EVALUATION OF APPLICANT PERSONAL QUALITY BELOW AVERAGE AVERAGE Maturity Ability to work/interact with others/team Initiative Dependability Courteousness Ability to learn Ability to follow directions Neatness & professional appearance Quality of work Friendliness Positive Attitude Would you recommend that we accept this person into the Junior Volunteer Program?
ABOVE AVERAGE
Yes _____
No____
Please explain why or why not. You may attach additional pages as necessary. _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Name (Please print)_______________________________________________
Date__________________________________
Signature __________________________________________________________
Work Phone_________________________
What is your relationship to the applicant, and how long and how well have you known him/her?
__________________________________________________________________________________________________________________________________
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
Mission Hospital Junior Volunteer Application Packet Junior Volunteer Reference Inquiry The student named below has applied to the Junior Volunteer Program at Mission Hospital and has requested that you provide a reference for him/her. This form should only be filled out by a current teacher. A reference completed by a teacher who is related to the applicant will not be accepted. Please remember that Mission Hospital is an acute care facility and that Junior Volunteers will interact with patients, families and hospital staff. Return this form at your earliest convenience. We cannot proceed with the application process until all reference forms are received. APPLICANT________________________________________________________________________________________________________________ Please check the appropriate spaces: PERSONAL EVALUATION OF APPLICANT PERSONAL QUALITY BELOW AVERAGE AVERAGE Maturity Ability to work/interact with others/team Initiative Dependability Courteousness Ability to learn Ability to follow directions Neatness & professional appearance Quality of work Friendliness Positive Attitude Would you recommend that we accept this person into the Junior Volunteer Program?
ABOVE AVERAGE
Yes _____
No____
Please explain why or why not. You may attach additional pages as necessary. _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Name (Please print)_______________________________________________
Date__________________________________
Signature __________________________________________________________
Work Phone_________________________
What is your relationship to the applicant, and how long and how well have you known him/her?
__________________________________________________________________________________________________________________________________
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
Mission Hospital Junior Volunteer Application Packet MISSION HOSPITAL JUNIOR VOLUNTEER VACCINE QUESTIONNAIRE _____________________________________________________________________ Name (Last, First, Middle)
Please print clearly
Question 1 Do you have a vaccine record with verification of two MMR vaccines OR one vaccine for Mumps, one for Rubella (German Measles) and two vaccines for Rubeola (Red Measles)? O Yes O No If yes, please provide a copy of the record to Volunteer Services. If no, please contact your personal physician to get an MMR titer to verify immunity, and provide confirmation to Volunteer Services. Question 2 Have you had the chicken pox?
O Yes
O No
If yes, please enter approximate date or age: ______________ If no, have you had the chicken pox (varicella) vaccine? O Yes O No •If yes, please provide a copy of the record to Volunteer Services •If you have no history of the disease and have not been vaccinated for it, please contact your personal physician to get a chicken pox (varicella) titer to verify immunity, and provide confirmation of your immunity to Volunteer Services. Question 3 Have you had the influenza vaccination this year?
O Yes
O No
If yes, please provide a copy of the record to Volunteer Services. If no, mandatory influenza vaccinations will be available at Staff Health Services. I verify this information is true and correct to the best of my knowledge. _______________________________________ Signature
____________________ Date
_______________________________________
____________________
Parent/Guardian Signature
Date
Notes: You will not be allowed to begin volunteering until copies of records or proof of immunity are on file with Volunteer Services Office if required as a result of answers provided in the questionnaire above. Annual TB skin tests are highly recommended for volunteers, unless you have previously tested positive. If you have ever had a positive test, please do not take the skin test, but instead complete a questionnaire annually. After initial testing upon entry into the volunteer program (mandatory), volunteers will be notified to update their test annually. A Flu Vaccine is mandatory for volunteers annually. It is available at no charge at Mission Staff Health and is usually available by mid to late October for the coming flu season. Tetanus vaccines should be updated every 10 years.
Volunteer Services 509 Biltmore Avenue, Asheville, NC 28801 Phone: 828-213-4187 | Fax: 828-213-4151 missionhospitals.org
