Junior Volunteer Application (Ages 14-18)

Volunteer Name:

Volunteer Age:

Volunteer Grade:

Junior Volunteer

Application

(Ages 14 - 18)

Medical Center Alliance

3101 North Tarrant Parkway

Fort Worth, TX 76177

Phone: 817-639-1000

Fax: 817-639-1727

If you are unable to drop off application at the front desk, you are

welcome to fax it to the number above.

Junior Volunteer Guidelines

Thank you for your interest in becoming a Junior Volunteer at Medical Center Alliance.

Please carefully read the guidelines and rules that apply to Junior Volunteers and have a parent or guardian read them also.

I. REQUIREMENTS

Jr. Volunteer Ages: 14 – 21

Forms: All Application Forms and other required forms must be completed before you will be considered for a Junior Volunteer position. The Following items are required:

• Copy of current Report Card (must maintain a "B" average or higher)

• Copy of current up-to-date immunization record

• 2 letters of recommendation from someone other than a family is required.

Screening:Every volunteer will have to pass a background check, drug screen and TB skin test before they can start. Interview: You will meet with the Volunteer Coordinator or Employee Health Nurse to discuss the Volunteer Guidelines, and requirements after you have completed all necessary paperwork.

Service: We require a minimum of 4 hours per week per semester of service as a Junior Volunteer. This usually begins in June and ends in September of each year but may be extended on an individual by individual case. Medical: Annual PPD (Tuberculosis screening) for all Volunteers is required within

30

days of your start date. Volunteers may have these tests at Medical Center Alliance at no charge. Parental/Guardian consent for PPD is required. Medical requirements must be completed BEFORE service begins.

Training: Volunteer Orientation attendance is required before you may start your service. You will be informed of the date and time of the orientation class after you are accepted to the program.

II. ATTENDANCE AND ABSENCES

Junior Volunteers become an integral part of their department and the Hospital staff relies on their presence as scheduled. We understand that all Volunteers may get sick, take vacations or have unavoidable conflicts (exams!) on their regular volunteer day. A message may be left on the Volunteer Coordinators phone at 817-639-1937 or 817-688-5858 when you are not able to fulfill your duties for that day.

Volunteers who have taken an extended leave of absence must contact the Volunteer Coordinator before returning to service. Similarly, please notify the Volunteer Coordinator if you are resigning from the Volunteer Service and return your

ID

badge.

III. UNIFORM AND DRESS CODE

Each Junior Volunteer is required to wear the correct approved Junior Volunteer uniform at all times while on duty. The Junior Volunteer required uniform is the following: Male and Female Junior Volunteer Uniforms are the same.

• Shirts- WHITE collared short or long-sleeve shirt.

• Pants - Khaki dress slacks. No hip hugger, low rider, or baggy pants allowed.

• Do not use perfume or other scented products as it may cause allergic reactions in some patients at any time while on duty.

IV. VOLUNTEER ASSIGNMENT AND SCHEDULES

Every Junior Volunteer is required to commit to an assignment of one 4 hour shift per week for a minimum of one semester commitment period. Weekend shifts are available IF APPROVED by Volunteer Coordinator.

You will be given one or more regular volunteer assignments based upon the needs of the Hospital. Every effort will be made to take into account your special interests and skills.

Available shifts as follows:

•

8:00 a.m. – 12:00 p.m.

Monday-Friday

•

1:00 a.m. – 5:00 p.m.

Monday-Friday

Jr.Volunteer’s duties include but are not limited to:

• Escort families, visitors to various areas as needed.

• Make Happy Cart rounds on all floors several times during your shift.

• Transport specimens, supplies, etc. to lab and other departments.

• Run errands as requested by unit staff

• Assist patient with meals - open containers, set up trays, etc.

• Help transport discharged patients off unit.

• Keep public areas tidy, uncluttered, reading materials provided.

• Any other duties as assigned by Director or Supervisor.

We expect our Junior Volunteers to continue their tradition of mature and responsible behavior at all times. This includes a willingness to accept supervision and to follow Hospital rules.

V. SIGN-IN PROCEDURE

When you arrive for your shift, sign in at the front desk located on the 1st floor. Contact the nursing supervisor at *91888

and have them sign you in/out. You are responsible for keeping track of the hours you work.Please do not bring valuables

or cash to the Hospital except for what you absolutely need.

VI. MEAL BREAKS

Your Volunteer Photo ID entitles you to one free meal in the cafeteria while on duty. Do not use your Volunteer Photo ID to purchase items from the cafeteria for anyone other than yourself.

VII. PARKING

I, on this day, have read the guidelines to the Volunteer Program. I hereby agree to all the terms and conditions to this program.

Signature of Jr. Volunteer ______________________________________________________

As the parent/ legal guardian of this junior volunteer, I have reviewed these requirements and give permission for them to participate.

Name: ________________________________

Signature: _______________________________ Date: _______________

In order to apply for this volunteer opportunity, you must read and agree to the terms as well as complete and return the attached forms to Medical Center Alliance front desk.

For questions on the process, please contact Alex Roberson, the volunteer coordinator at 817-688-5858 or email

JR. VOLUNTEER APPLICATION

Please print clearly and answer all questions, which apply to you:

Last Name First Name Middle Name

Home Address City State Zip Code

Home Phone Cell Phone

Email Address: _____________________________________________________________________________________________

Do you work? Y or N If yes, where do you work? May we call you at work? During what days and hours? Student Grade Level _________ What school do you attend? ___________________________________________

Days Available: Monday Tuesday Wednesday Thursday Friday

Time Available: Morning or Afternoon

Volunteer Category: Junior (14 to 21 years of age)

Volunteer Experience

Please list any volunteer experience, including school and church volunteer activities: Agency City. State Dates Duties

Training, Education, Certification

Please list any special training, licenses, certifications or degrees:

Special interests

Please list your hobbies, skills or areas of special interest:

References

Please list two adult personal references, other than relatives, whom you have known for at least two years:

CONFIDENTIAL MEDICAL DISCLOSURE

This form is not to be kept in the volunteer file. It is to be forwarded to Employee Health Nurse immediately upon completion.

Name: ____________________________________________________ Date: _______________________________________ Address: _______________________________________________________________________________________________ Contact Number: _____________________________

Emergency Contact(s)

Name: _______________________________________ Relationship to you: ________________________________________ Address: _______________________________________________________________________________________________ Phone Number: ________________________________________

Name: _______________________________________ Relationship to you: ________________________________________ Address: _______________________________________________________________________________________________ Phone Number: ________________________________________

Please list any medical conditions you have:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

I certify that the above information is true and complete to the best of my knowledge at the time of application

to become a volunteer at Medical Center Alliance. I understand that it is my responsibility to update this

information with the Employee Health Nurse or Volunteer Coordinator if any changes occur. I hereby give

Medical Center Alliance permission to release pertinent information in the event of a medical emergency.

Signature: _____________________________________________ Date: __________________________