YOUTH VOLUNTEER PROGRAM Thank you for considering the Yale-New Haven Hospital Youth Volunteer Program as the place you want to be! Yale-New Haven Hospital is one of the top hospitals in the United States and is proud to

have one of the most established volunteer programs. Our Youth Volunteer Program was one of the first in the country, and has been used as a model for other hospitals. Please give serious consideration to the commitment required to have a great volunteering experience at YNHH. The popularity of this program

cannot be overstated; if you want to volunteer, please act now so you don’t miss out on a great opportunity to volunteer at Yale-New Haven Hospital! PLEASE NOTE: We are only accepting new students for the Yale-New Haven Hospital/York Street Campus for the 2013-2014 academic year. Students must be 15 years of age or older. This information sheet will answer many of your questions, so please review this information with your parent/guardian and if you are then ready to make a commitment, please follow the next steps outlined at the end of the packet. We hope you will decide to join us.

APPEARANCE: You represent Yale-New Haven Hospital, and your appearance reflects on the hospital. A clean, neat, professional appearance is important to promote the professionalism expected by patients and visitors. We have a standards of appearance policy that you will be expected to follow. You will be given a red YNHH volunteer polo shirt to be worn with khaki pants. Jeans, shorts, capris, and sandals are not permitted. All employees, physicians and volunteers are required to wear hospital issued ID badges. ATTENDANCE:

Your presence is important, and we depend on you to report for duty as scheduled. It is your responsibility to report all absences to your department supervisor, as well as the Volunteer Services Department.

Repeated unexcused absences will be considered a lack of interest, and will result in termination of your volunteer status. You will be required to sign in and out each time you come to volunteer. CELLULAR PHONES and COMMUNICATION DEVICES: You may not use your personal cell phone or communication device for non-hospital business while on duty

as a volunteer. If you need to be reached emergently, your parent may call the Volunteer Services Department and we will find you.

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COMMITMENT:

Commitment for a minimum length of time and/or volunteer hours of service is required for Yale-New Haven Hospital volunteers. This is due to the application and training requirements and the need for consistency of volunteer attendance. The minimum commitment for youth volunteers is 50 hours of service. •

During the academic year, youth volunteers are expected to volunteer 3–6 hours per week. There are available shifts after school and on Saturdays.

COMMUNITY SERVICE HOURS: For students who have community service hours to complete for school, service clubs, or religious organizations, the number of hours you are required to complete will be calculated at the completion of your

50 hour commitment. For instance, if you are required to perform 10 hours of service, you must first

complete 40 hours of volunteer service, and then the last 10 hours of your commitment to the hospital will be considered your service requirement hours. Likewise, if your service requirement for school is for 30 hours, you must first complete 20 hours, and your final 30 hours will be considered as your service requirement hours. If you have questions about this, please contact Volunteer Services for clarification. EVALUATION:

Your supervisor will complete an evaluation of your performance and this will become part of your record in Volunteer Services. This information will be used to help you improve and also for references. HEALTH REQUIREMENTS:

Volunteers are required to meet health requirements, to assure patient safety. We will give you a health form to be completed by your physician and you will need to provide verification of immunizations. All

volunteers are required to have an annual tuberculin skin test (PPD). Your acceptance into the Youth Volunteer Program will not be finalized until you have met the necessary health requirements. INTERVIEW: First year applicants will be interviewed in the Volunteer Services Department. The interview will last between 20 and 30 minutes; please arrive on time. The Volunteer Services Department is located

adjacent to the Atrium, the Gift Shop and the Cafeteria, so there are things for parents/guardians to do during your interview, if they accompany you to the hospital. MEALS:

After school youth volunteers are entitled to a complimentary snack each time they volunteer. You will

receive a $3.00 snack card upon arrival to be used in the hospital cafeteria; if you spend more than $3.00, you will be responsible for the balance.

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PARKING:

The hospital provides free parking to volunteers. If you will be driving to the hospital, please remember to pick up a parking registration form during your interview. REFERENCES: Many youth volunteers request references for college and scholarship applications. We are pleased to provide a reference for you IF you have fulfilled your commitment to the hospital. Attendance records and

evaluations are considered when preparing references. Reference requests require a one week advance notice.

ORIENTATION:

After you attend your volunteer interview you will be given a list of dates and times available for the General Orientation Session, which is a requirement in order for you to volunteer. All orientations will be held on the York Street Campus. TRAINING:

Training will be provided for your specific assignment. Some assignments require attendance at a group

training session prior to the start of the program. Training for the other assignments will be done on the volunteer’s first day. Once assigned, we will advise you of your training schedule. VALUABLES: There are a limited number of lockers in the Volunteer Services Department for your valuables. Please always leave the key in the lock when removing your belongings. However, we strongly encourage you not to bring valuables with you. You are responsible for your personal belongings. _________________________________________________________________________

NEXT STEPS •

Complete the application form and attach a one page reflection. Bring both the application and reflection with you to the interview. QUESTIONS ?

Volunteer Services Department 203-688-2297

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YOUTH VOLUNTEER APPLICATION Today’s Date _____________/_______/_________

Please PRINT! Complete BOTH SIDES of the application and attach a one-page reflection. Bring both the application and reflection with you to the interview. Assignments are scheduled based on availability and volunteer position openings. Last Name:

First Name:

MI

Street Address:

City:

State

Home Telephone:

Zip

Cell Telephone:

E-mail Address:

Birth Date:

EMERGENCY CONTACT Name:

Relationship:

Street Address: City:

State

Home Telephone:

Cell Telephone:

Zip

Business Telephone:

E-mail: Physician:

Telephone:

Name of school: Current school year:

Freshman

Sophomore

Career interest:

Junior

Senior

Special skills and talents:

Will you carpool with another volunteer?

Yes

No

If so, whom?

Do you have a parent/relative currently employed at Yale-New Haven Hospital?

Yes

No

If yes, please complete the information below: Name: _____________________ Relationship: __________________ Department: ___________________ Name: _____________________ Relationship: __________________ Department: ___________________ Name: _____________________ Relationship: __________________ Department: ___________________ What size polo shirt do you wear?

S

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M

L

XL

XXL

VOLUNTEER and COMMUNITY ACTIVITIES Please tell us about your volunteer experience and community activities. AGENCY/ORGANIZATION

POSITION

DATES

YOUR PREFERENCES SCHEDULE: Please check the days that you are available to volunteer on a regular basis. AFTERNOON 3:00 – 6:30PM Monday Tuesday Wednesday Thursday Friday

ASSIGNMENT PREFERENCE: Please check the types of volunteer assignments that interest you. The examples listed in parenthesis are just examples, not the only assignments in each category.

Behind the Scenes / Staff Support (office work, computer work, supply areas) Customer Service (information desks, gift shop, ambassador, family waiting areas, flower delivery) Patient Support (book cart, patient visitor, patient transport, art cart) Patient Contact (patient aide on nursing unit, pediatrics) Offsite Locations (Childcare Center, Sister Anne Virginie Grimes Center, North Haven, Shoreline Medical Center- Guilford, Temple Medical Center)

REFLECTION: Please attach a one page reflection. Topics can include but are not limited to: a personal story, future career goal; aspirations; reasons for wanting to volunteer, etc. th

Have you ever been found guilty of a misdemeanor or felony since your 16 birthday?

Yes

No

A conviction is not an automatic disqualification for a volunteer position.

For students under age 18, a parent/guardian signature is required. I hereby accept to volunteer without pay at Yale-New Haven Hospital. I certify that the information that is provided on this application is complete and true. I further acknowledge falsification or omission of any significant information presented or requested on this application or during the interview process may result in rejection for a volunteer position or dismissal. Applicants Signature: _________________________________________________ I give permission for ________________________ to volunteer at Yale-New Haven Hospital, and to be photographed in relation to his/her volunteer position. Parent/Guardian Signature: ___________________________________________

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VOLUNTEER SERVICES DEPARTMENT SCHOOL REFERENCE FORM Volunteer Applicant:________________________________________________________________________________ The above names student has applied for volunteer service at Yale-New Haven Hospital. It is important that we obtain background information on this applicant. A prompt reply will be greatly appreciated and the information will be regarded as confidential. Please return this form directly to: Yale-New Haven Hospital, Volunteer Services Department, 20 York Street, New Haven, CT 06510 or fax to 203-688-4363. Students grade/year in school: How long have you known the applicant? Is the applicant courteous with adults?

Yes 

No 

Does the applicant make friends easily?





Has the applicant ever received an unsatisfactory report in citizenship or conduct?





Has the applicant maintained a satisfactory attendance record at school?





Does the application follow directions well?





Do you believe the applicant would ask questions when not sure of what to do?





In which area(s) do you feel this student will be most comfortable and successful? a. In patient care assignment on one unit when s/he will interact directly with patients in an intense setting. b. In a patient contact assignment where s/he will meet many different patients and have less emotional involvement. c.

In a busy non patient area which will offer task orientated responsibilities in a structure environment.

d. In a non-patient area which will offer task oriented responsibilities in a structured environment.

Please make any additional comments which will help us appropriately place this student: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Signature: ______________________________________________________________________ Date: ____________ Title: ____________________________________________________________________________________________ School: _______________________________________________________Telephone: _________________________

All information will be regarded as confidential. Please return this form directly to the Volunteer Services Department as promptly as possible; acceptance of students is delayed until this form is received. Thank you for your cooperation. For questions call: 203-688-2297. C:\Documents and Settings\heroldd8\Desktop\2013_14_acad_youth_app.doc

VOLUNTEER HEALTH QUESTIONNAIRE SIDE ONE - TO BE COMPLETED BY YALE-NEW HAVEN HOSPITAL VOLUNTEER APPLICANT Please carefully read and answer the following questions and return this form to the Volunteer Services Department or fax to: 203-688-4363

Name: When did you have your most recent physical exam? Have you ever had or been exposed to tuberculosis? Have you had a chronic cough for more than 2 weeks? Have you had a TB skin test (TST)?

Yes

No

Yes

No

When?

Result?

If you had a positive TST did you have a chest x-ray? Do you have a chronic or recurrent rash or skin infection? Have you had chronic diarrhea?

When?

Result?

Yes

No

Yes

No

List any medications you are currently taking (prescribed or otherwise):

Do you have any physical disabilities which may affect your placement or job duties?

I, the undersigned, hereby authorize my physician to release the medical information on the reverse side to the volunteer services department for the purpose of evaluating my medical appropriateness for volunteering in the hospital setting.

Signature of Applicant

Date Signed

Signature of Parent (If applicant is a minor)

Date Signed

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SIDE TWO - TO BE COMPLETED BY PHYSICIAN OR HEALTH CARE PROVIDER

Name of Volunteer: Date:

Birthdate:

The above mentioned person has applied to be a volunteer in our hospital and has given your name as a health reference. Please review the health questionnaire and authorization on the reverse side, complete the bottom portion of this page and mail to: Yale-New Haven Hospital Volunteer Services, 20 York Street, New Haven, CT 06510 or fax to: 203-688-4363. This information will be regarded as confidential. Please keep in mind that a volunteer may be assigned to work directly with patients or in an assignment that would require physical exertion such as pushing or walking. Any comments you can make which would aid us in making an appropriate placement would be appreciated. Thank you for your cooperation in helping us to offer volunteer services within the hospital. Volunteer Services Department (203) 688-2297.

In your opinion, is this applicant physically and emotionally able to volunteer at Yale-New Haven Hospital?

Yes__________

No__________

Limitations or special attention: Check here if you wish to speak with the Director of Volunteer Services:__________

Signature of Physician/Health Care Provider

Date

Address

Telephone

Please provide any information you have regarding the following: DATE(S) 1. TUBERCULOSIS SCREENING TST (Tuberculosis Skin Test) Chest X-ray (if TST is positive) 2. RUBELLA SCREENING Rubella Immunization Rubella Titer for Immunity 3. MEASLES SCREENING (if born after 1/1/57) Measles Immunization Measles Titer for Immunity 4. MUMPS SCREENING (if born after 1/1/57) Mumps Immunization Mumps Titer for Immunity 5. VARICELLA (Chicken Pox) SCREENING Varicella Immunization Varicella Titer for Immunity History of Disease 6. HEPATITIS B SCREENING Hepatitis B Immunization Hepatitis B Titer for Immunity

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