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1 Volunteering as a Teen at St. Mary Note: We appreciate your attention to detail with concerns to completing this application. It is imperative that we be compliant with the various accreditation regulations for the hospital for both paid and unpaid staff. With that said, please note that the total process time to become a volunteer at St. Mary Medical Center is approximately one to two months. Eligibility: Applicants must be between years of age. Juniors may volunteer throughout the school year with hours after school or on the weekend. Summer Program Volunteers Applications for this program must be received by March 1 st. If accepted into the program, an will be sent regarding the date and time of your interview/orientation. Orientation/interview is held on one Saturday early in May. On that day please be prepared to know which day/time you are available to volunteer through the summer. You must have transportation to the hospital for the days/times you choose. Junior volunteers are not permitted to linger at the hospital waiting for a ride before or after their assignment. Summer program volunteers we require a minimum of 30 hours or one 5 hour shift per week for eight weeks. If you do not complete the minimum required hours, we will not process any requests for hour s documentation. Also, if you play sports or take an extended vacation and will not be able to complete the 6 out of the 8 week program, please reconsider submitting an application. It takes considerable time and effort to prepare to become a volunteer and consistency is what makes this program beneficial to you the volunteer and to St. Mary Medical Center. All communications will be through , so please be sure we have your and your parent s to avoid miscommunication. Process: 1) Complete and return the teen application. Applications may be faxed, ed or mailed and should be returned as one packet. Please make a copy for your records. 2) After you have returned your application please call our office to schedule a personal interview. This is only for year round volunteers. Our interview line is During the interview we will discuss the various assignments available as well as your schedule and qualifications. Placement and scheduling will be made at that time. You must sign up for a mandatory 3 4 hour Orientation at the time of the interview. Spaces may be limited; therefore, you will be directed to the next available orientation at the interview. Teen volunteers are limited to certain areas of the hospital, and volunteers are expected to be flexible and accepting of various assignments. 4) Please be aware that the application process also includes the following requirements. Arrangements and directions will be provided during your interview. Background and Excluded provider check and photo ID to be completed through our Human Resources Department. Provide proof of a recent two step PPD test, and an annual influenza immunization, or can obtain these through St. Mary. Commit to at least 100 hours of service to St. Mary for year round volunteers. 5) Thank you for your interest and desire to be a part of St. Mary Medical Center s Volunteer Department. Please submit application materials and forward any questions regarding volunteering to: Stacy Ferguson Coordinator, Volunteer Services 1201 Langhorne Newtown Rd Langhorne, PA phone fax

2 St. Mary Medical Center Department of Volunteer Services Volunteen Application Summer Only Year Round Volunteer ================================================================= Title: Mr. Miss Please Circle One: Male or Female Name: (Last) (First) (Middle) (Nickname) Address: City/State/Zip:, Home Phone: Cell Phone: H.S. Graduation Year: Parent E mail: Uniform Polo Size Date of Birth: (Minimum age to volunteer is 16) Work Experience: Past Volunteer Experience: Do you agree to commit to 100 hours of volunteer service? Yes No Please consider the following questions to help you determine which type of volunteer assignment you would prefer and check off your choice below. Direct Patient Care: Are you comfortable being around people who are sick? Would you be comfortable entering a patient s room? Are you comfortable approaching patients of various ages and diverse populations? Do you have an interest in going into the medical field; i.e. Nursing, Doctor, Rehab, Technician? If you have answered YES to most of these questions, you might be interested in one of our direct patient care assignments. Please indicate this on your application so we can assign you to the proper colleague for your interview.

3 Non-Direct patient care Do you like to be active and walk a lot? Do you prefer office type assignments, filing, copying, or answering phones? Are you good with directions? Are you comfortable talking with and helping people of various ages? Are you good on the telephone? If you have answered YES to most of these questions, you might be interested in one of our nondirect patient care assignments. Please indicate this on your application so we can assign you to the proper colleague for your interview. Type of Volunteer Service that you prefer: Patient Care Non-Patient Computer Clerical Are you interested in a Medical Career? Yes No School Activities: How did you find out about our Volun-teen program? Foreign Language: Yes Which Language Is there a friend you would like to volunteer with? Yes No Friends Name: TO THE PARENT: My daughter/son is applying to volunteer at St. Mary Medical Center with my full knowledge and approval. I understand that my child is required to perform a minimum of 100 hours of service prior to our office completing any school documents or providing letters of recommendation. Signature of Parent/Guardian: Date: Please return to: St. Mary Medical Center or Fax to Volunteer Office 1201 Langhorne-Newtown Road Langhorne, PA 19047

4 Is this part of a Court Ordered Community Service? Yes No Is this part of a Non-Court Ordered Community Service program? Yes No (This does not mean school mandated community service, but other law enforcement agency) Please explain: Do you have any criminal charges pending? Yes No Have you ever been convicted of a felony or misdemeanor? Yes No Conviction of a felony will bar you from volunteering at St. Mary Medical Center. However conviction of a misdemeanor will not necessarily be a bar for volunteering. Please describe the nature of the conviction, the date of the conviction and your rehabilitation since your conviction. I am a participant in a Youth Aid Panel Program for Township. I am required to perform Community Service Hours. In applying for volunteer services at St. Mary Medical Center, I certify that the above information is accurate and correct to the best of my knowledge. I authorize St. Mary Medical Center to investigate my record and obtain any and all information necessary for volunteer consideration. I also understand that I am applying for a non-paid volunteer assignment and do not expect remuneration for my services. If you fail to disclose anything in this section your application may be denied. Printed Name: Applicant Signature: Date: St. Mary Medical Center is an equal opportunity employer and will not discriminate on the basis of race, creed, religion, color, national origin, ancestry, age, sex, sexual orientation, familial status, marital status, disability and liability for service in the United States Armed Forces or other legally protected status.

5 Medical Information Parents Please Complete: Volun-Teen Name: Date of Birth: Prior to volunteering, please provide the following update on your child s immunizations. IT IS REQUIRED THAT YOUR CHILD HAS A BOOSTER BETWEEN THE AGES OF FOUR (4) AND SIX (6). THIS FOLLOWS THE GUIDELINES OF THE PA SCHOOL IMMUNIZATION REQUIREMENTS AS WELL AS AREA SCHOOL DISTRICTS. This form must be completed with dates and returned to the Volunteer Services Office prior to the interview. Immunizations DPT (Diphtheria, Pertussis, Tetanus) MMR (Measles, Mumps, Rubella) Flu Year of Immunization Lot# I give my permission for mandatory T.B. Skin Testing and verify that my child has not been treated for exposure to tuberculosis nor had a previous positive T.B. Skin Test. Medical Information: If your child has any medical condition(s), and/or is taking any special medication(s), it is important to let us know so that in the event of an emergency resulting from his/her illness, we can immediately contact you and medical personnel can provide proper treatment. NOTE: ALL INFORMATION REMAINS CONFIDENTIAL. List any allergies, medication reactions or other conditions that may need to be known in an emergency situation. Parent/Guardian Signature: Date: Parent Phone: Emergency Contact Other than parent: Name: Phone: Your Child s Physician: Phone:

6 SCHOOL COUNSELOR/TEACHER RECOMMENDATION My son/daughter,, has applied to volunteer at St. Mary Medical Center s Junior Volunteer Program. I hereby give my permission to release the attached information about my child to: Volunteer Services, St. Mary Medical Center, 1201 Langhorne-Newtown Road, Langhorne, PA Signature of Parent or Guardian Information will be kept confidential Date NAME OF STUDENT: Current School Year: School Attendance: Good Poor Is student passing all subjects? CHARACTERISTICS: Above Average Average Poor Leadership ( ) ( ) ( ) Follows Directions ( ) ( ) ( ) Mental Alertness ( ) ( ) ( ) Cooperation ( ) ( ) ( ) Appearance ( ) ( ) ( ) I recommend this student for volunteer services: YES NO If you have any questions about this application or the volunteer services program, please contact Stacy Ferguson at Counselor/Teacher Signature Date School Name: Phone: Personal Reference: As a Teen Volunteer, you are required to obtain a personal recommendation from a school counselor, as noted above; as well as two more from either a teacher or adult non-family member who has worked with you in a supervisory capacity. Your application will not be accepted until these recommendations have been received. Blank recommendation forms are attached. Please bring them with you to your interview or ask for them to be mailed to our office.

7 Once the application is completed and the recommendations received, please call the office to schedule an interview. After Orientation you will be required to pay $15.00 for a uniform. Uniforms for teens consist of a Red Polo shirt purchased here and khaki pants not provided. After your interview and orientation you will be required to have a photo ID taken and a background check at our Human Resources department between noon and 4:45 pm Monday through Friday before you can volunteer. Any High School or Lincs Proof of hours please or call Stacy Ferguson at providing 48 hours in advance for signatures and print out of hours. If you are requesting us to sign your Lincs papers, please prepare them in advance for signature. Thank you for your cooperation! Photography Release Form Consent is hereby given to St. Mary Medical Center, and to the Communications Department of St. Mary to obtain photographs of me or my wards at hospital request. These photographs may be released to the news media (newspapers, television, etc ) if desired. The photographs taken may also be used for education purposes and in promotional materials for St. Mary Medical Center. With my signature, I agree to these terms. Date: Volunteer Printed Name Signature (if under 18, please have parent or guardian sign) Security Prox Card Prox cards allow access into secure areas of the hospital. If my assignment warrants the issue of a Security Prox Card, my signature below indicates that I will return this prox card upon termination of my volunteer activities at St. Mary Medical Center. Lost cards cost $5.00 and I MUST NOTIFY the office immediately if lost. Date: Volunteer Printed Name Signature

8 ST. MARY MEDICAL CENTER VOLUNTEER REFERENCE FORM I, give my permission to Volunteer Services at St. Mary Medical Center to contact the person named below as a reference. I understand that the information can be used to determine my placement as a volunteer. Signature: Date: Reference Information Name of Reference: Relation to Applicant: Reference Telephone: Are you familiar with the applicant s work habits? Yes No How long have you known the applicant? Years Months In what capacity? Work School Other Reference: Please check the appropriate columns Below Average Average Above Average Have not observed Quality of work Quantity of work Knowledge and Skills Dependability/Attendance Relationship with others Acceptance of Supervision Originality In your opinion, would this person work well as a volunteer at St. Mary Medical Center? Do you recommend this individual for a volunteer assignment at St. Mary Medical Center? To the best of your knowledge, has this applicant ever been involved in any criminal activity? Signature of Reference Date Please return form to: St. Mary Medical Center or Fax Volunteer Services 1201 Langhorne Newtown Road Langhorne, PA 19047

9 ST. MARY MEDICAL CENTER VOLUNTEER REFERENCE FORM I, give my permission to Volunteer Services at St. Mary Medical Center to contact the person named below as a reference. I understand that the information can be used to determine my placement as a volunteer. Signature: Date: Reference Information Name of Reference: Relation to Applicant: Reference Telephone: Are you familiar with the applicant s work habits? Yes No How long have you known the applicant? Years Months In what capacity? Work School Other Reference: Please check the appropriate columns Below Average Average Above Average Have not observed Quality of work Quantity of work Knowledge and Skills Dependability/Attendance Relationship with others Acceptance of Supervision Originality In your opinion, would this person work well as a volunteer at St. Mary Medical Center? Do you recommend this individual for a volunteer assignment at St. Mary Medical Center? To the best of your knowledge, has this applicant ever been involved in any criminal activity? Signature of Reference Date Please return form to: St. Mary Medical Center or Fax Volunteer Services 1201 Langhorne Newtown Road Langhorne, PA 19047

10 FOR OFFICE USE ONLY File Checklist Application sent rec d Entered into Raiser s Edge Summer Year Round Name: Reference 1 Reference 2 Medical Information Sheet School Counselor/Teacher Recommendation form Interview Assigned Service Guideline Training Checklist Background Code of Conduct ID Scanned Orientation Unit Inservice TB Test #1 date #2date Excluded Provider Background check Photo Release Form Security wafer/proxcard # Office Use Only: Interview Date: ID Completed Start Date: Training with: Date: Availability: Weekdays Evenings Weekend Orientation: Distribution List Scheduled: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Hours: Assignment/Dept:

11 Emergency Medical Contact Form Volunteer Information: My Name: My Phone: My Date of birth: My Emergency contact information: Name of Emergency Contact: Phone: Relationship: Family Physician: Phone Number:

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