Web - teen application 2008

TEEN VOLUNTEER APPLICATION

6900 North Durango Drive 2075 E. Flamingo Road 5400 Rainbow Boulevard

Las Vegas, NV 89149 Las Vegas, NV 89119 Las Vegas, NV 89118

(702) 835-9861 (702) 369-7782 (702) 853-3059

657 Town Center Drive 620 Shadow Lane

Las Vegas, NV 89144 Las Vegas, NV 89106

(702) 233-7532 (702) 388-4668

Which hospital(s) are you volunteering for? Centennial Hills Hospital Desert Springs Hospital

Spring Valley Hospital Summerlin Hospital Valley Hospital

V aluable for all you are and all you do.

O pen to trying new things.

L oyal and reliable day after day.

U ntiring in your willingness to help.

N ice to be around.

T houghtful in so many caring ways.

E ager to share your talents and skills.

E nergetic in every task you take on.

R eady with a smile to brighten another’s day.

S pecial. That’s what volunteers are!

Teen Volunteer Application – Page 2

VALLEY HEALTH SYSTEM – TEEN VOLUNTEER APPLICATION

PLEASE PRINT CLEARLY Date: ___________________ Social Security #: ___________________________________

Name: ________________________________________________________________________________________ Mr. Miss

Last First Middle (circle one)

Address: ____________________________________________________________________________________________________

Number & Street City State Zip

Home Phone: _______________________ Cell Phone: ________________________ Birthdate: __________________ Age: ______

Email Address: _______________________________________________________________________________________________

Parent or Guardian’s Name and Cell Phone #: ______________________________________________________________________

Name of School: ______________________________ Graduation Year: __________ GPA: ___________ Grade: __________

Address of School: ____________________________________________________________________________________________

Number & Street City State Zip

Career Planned: _________________________________________________________ Are you now employed? Yes No

Name of Employer: _________________________________ Phone: ____________________ Position: _____________________

Extra curricular activities/hobbies: _______________________________________________________________________________

Why do you want to be a volunteer? ______________________________________________________________________________

What does customer service mean to you? _________________________________________________________________________

Previous/current volunteer experience: ____________________________________________________________________________

Agency or Company Name Position

____________________________________________________________________________________________________________

Agency or Company name Position

Who encouraged you to volunteer: _______________________________________________________________________________

Have you ever been convicted of a felony? Yes No When? ___________________________________________

If yes, describe: ______________________________________________________________________________________________

PERSON TO BE CONTACTED IN AN EMERGENCY:

Name: ____________________________________ Relationship________________________ Phone: ______________________

Address: ______________________________________________________________________ Cell: _______________________

Number & Street City State Zip

How much time can you give? Days per week ______________________ Hours per day ______________________

Check the day that you are able to volunteer: Monday Tuesday Wednesday Thursday

Friday Saturday Sunday

Times available: Morning 8:00 a.m.-noon Afternoon noon-4:00 p.m. Evening 4:00-8:00 p.m.

Teen Volunteer Application – Page 3

IF ACCEPTED AS A HOSPITAL VOLUNTEER, I AGREE THAT:

1. I shall hold as absolutely confidential, all information that I obtain directly or

indirectly concerning patients, doctors or personnel, and not seek to obtain

confidential information.

2. My services are donated to the hospital without contemplation of compensation or

future employment, and given with humanitarian, religious or charitable reasons.

3. I shall submit to an annual tuberculin skin test and any other health examination

which may be necessary as part of my volunteer service.

4. I understand that it is required I take safety and educational classes yearly.

5. I shall be punctual and conscientious, conduct myself with dignity, courtesy and

with consideration of others, and endeavor to make my work professional in

quality.

6. I shall make my best effort to fulfill my commitment to the hospital by

completing all assignments that I accept.

7. I shall at all times uphold the philosophy and standards of the hospital.

8. I understand that the Volunteer Services Department reserves the right to

terminate my volunteer status as a result of (a) failure to comply with hospital

policies, rules and regulations; (b) absences without prior notification; (c)

unsatisfactory attitude, work appearance; or (d) any other circumstances which, in

the judgment of the department director, would make my continued services as a

volunteer, contrary to the best interests of the hospital.

I have read each of the above conditions and I agree to be bound by them as well

as all hospital policies and procedures with The Valley Health System.

_______________________________________________ ______________

Volunteer Signature Date

INSTRUCTIONS: Please have your parent/guardian complete page 4.

Your guidance counselor or a current teacher must complete page 5 and

return entire application to the Volunteer Services Department.

Teen Volunteer Application – Page 4

PARENT OR GUARDIAN CONSENT FORM

CONSENT TO VOLUNTEER:

If accepted, I _______________________________________(parent/guardian name)_ agree to cooperate with

him/her in complying with the Volunteer Services rules and regulations which include providing transportation,

wearing the prescribed uniform, and ensuring that he/she faithfully maintains his/her weekly volunteer

schedule.

I further concur that while on duty he/she is to remain on hospital property unless otherwise instructed by me. I

understand that if the Teen Volunteer does not comply with policy, this may be grounds for immediate releasing

of the volunteer from hospital service.

I understand that he/she must have the two step tuberculin skin test prior to volunteering and that The Valley

Health System will administer this test at no cost to me. I further understand that the Teen Volunteer must

attend an orientation and have the tuberculin skin test annually in order to continue volunteering.

Parent/Legal Guardian Signature: _______________________________________ Date: ___________

Parent/Legal Guardian Name: __________________________________________

Please Print

CONSENT TO RELEASE SCHOOL RECORDS:

Name of Student: ___________________________________________________________________________

School: _____________________________________________ School Phone: _______________________

I hereby:

• authorize a representative of the above school to complete the reverse side (School Guidance

Counselor/Teacher Evaluation Form) in connection with the above student’s application to

participate in the Teen Volunteer Program at The Valley Health System.

• I understand the purpose of the form is to aid The Valley Health System in selecting qualified Teen

Volunteers. All information provided by the school would remain confidential.

Parent/Legal Guardian Signature: _______________________________________ Date: ___________

Parent/Legal Guardian Name: __________________________________________

Please Print

Teen Volunteer Application – Page 5

SCHOOL GUIDANCE COUNSELOR/TEACHER

CONFIDENTIAL EVALUATION

Student Name: _______________________________________ Birthday: ___________________________

School: _____________________________________________ Grade: ______________________________

I would rate this student as follows:

1. Requires less more about the same amount of instruction as most students.

2. Requires minimal occasional considerable supervision or direction.

3. Does Does not follow through on assignments.

4. Gets along not well well very well with peers.

5. Gets along not well well very well with older persons.

6. Has Has not shown adequate emotional stability to work with hospital patients.

7. Does Does not exhibit general appearance of neatness.

8. Is Is not regular in school attendance.

If not regular, what is the cause of absence/tardiness? _____________________________________

I recommend this student be accepted as a Teen Volunteer with The Valley Health System.

I DO NOT recommend this student be accepted as a Teen Volunteer with The Valley Health System.

Comments: ________________________________________________________________________________

__________________________________________________________________________________________

Signature: ___________________________________________________ Title: _______________________

Print Name: _________________________________________________ Date: _______________________

Please return evaluation to the student or mail/fax to the Volunteer Services Department at:

Centennial Hills Hospital, 6900 North Durango Drive, Las Vegas, NV 89149 (702) 835-9861 (fax) 835-

Desert Springs Hospital, 2075 E. Flamingo Road, Las Vegas, NV 89119 (702) 369-7782 (fax) 369-7836

Spring Valley Hospital, 5400 Rainbow Boulevard, Las Vegas, NV 89118 (702) 853-3059 (fax) 853-8609

Summerlin Hospital, 657 Town Center Drive, Las Vegas, NV 89144 (702) 233-7532 (fax) 233-7599

Valley Hospital, 620 Shadow Lane, Las Vegas, NV 89106 (702) 388-4668 (fax) 388-4618

Teen Volunteer Application – Page 6

WANTED: HOSPITAL VOLUNTEERS

WHAT’S A HOSPITAL VOLUNTEER? They are a special, wonderful kind of person who offers his or her

time, free of charge, to help others.

WHY ARE HOSPITAL VOLUNTEER IMPORTANT? Because they provide many EXTRA services that

supplement the basic, essential functions of the staff…services that add to the comfort, care and happiness of

the patient! Volunteer add to the quality of health care by helping the patients, their families, the staff and

visitors.

BUT WHAT DOES THE VOLUNTEER GET OUT OF THIS? A chance to learn new skills, develop new

interests, make new friends and most of all, a chance to enjoy that rare satisfaction that comes from helping

others.

WHAT KIND OF PEOPLE ARE VOLUNTEERS? Men and women of all ages, all backgrounds, and all

abilities. They may be students, housewives, working people or retired people.

WHAT QUALIFICATIONS ARE NEEDED?You need to be interested, have a good attitude, be dependable

and be discreet.

PREPARATION FOR THE JOB? First we will interview you to match your interests, talents and schedule to

the hospital’s needs. We will then orientate you to the hospital and its goals, uniform requirements, policies and

procedures, and your benefits. Once you have completed all our requirements (including a two-step

tuberculosis screening), you will be introduced to your assignment and contact person. Then you will be ready

to begin volunteering!

And many thanks to you for volunteering at our hospital!

To be completed by the Volunteer Services Department

Interviewed: ___________________________ Orientation: __________ TB Test: _________

First day Scheduled: _____________________ Supervisor Notified:_______________________

Assignment: ___________________________ Day/Time: ______________________________

Comments: ________________________________________________________________________

__________________________________________________________________________________