STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16*

Transcription

1 STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16* CONTACT INFORMATION Name: Date: Address: Phone Number: EMERGENCY CONTACT INFORMATION Emergency Contact: Relationship: Home Phone: Cell Phone: SCHOOL INFORMATION Select one: High School Student College Student Other: School Name: Major/High School Programs: Current Grade level: STUDENT AVAILABILITY Please indicate your availability: Start Date: End Date: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Preferred amount of hours per week: Please list any pre-planned holidays or vacation days scheduled: T-shirt Size (unisex sizes): Small Medium Large X-Large Would you be willing to drive to one of our remote locations? Yes No Bowie Kent Island Odenton Waugh Chapel *For office use only Date Received: Placement: Immunizations: Complete Incomplete Orientation: Badge Appointment Scheduled for: Notes:

2 Personal Questions (Please write legibly and be specific!): Is there a particular area of the hospital where you would like to gain experience? What interests you in volunteering in the hospital environment? What do you hope to gain from your experience? What are your plans for the future? Please list previous volunteer experience: List 3 characteristics that describe you: 1.) 2.) 3.) List 3 areas of opportunities for growth: 1.) 2.) 3.)

3 VOLUNTEER AND INTERN AGREEMENT In consideration of, (volunteer/intern) having the opportunity to participate in a volunteer/intern program at Anne Arundel Medical Center ( AAMC ), I agree to the following: 1. Release of Liability: I understand that the intern/volunteer will be working in a medical facility and may be exposed to a full range of human medical conditions from minor illness to death. I hereby release, discharge and agree to hold harmless AAMC, its affiliates, employees, officers, agents and directors from any and all liability, claims or demands of any nature including but not limited to, those for personal injury, death, and/or property damage or loss, of any nature whatsoever which may be incurred by the volunteer/intern in any way related to the volunteer/intern s participation in the Program. I agree to hold harmless and indemnify AAMC, its affiliates, employees, officers, agents, and directors, from any liability or damages incurred as a result of any acts or omissions of the volunteer/intern. 2. Immunizations: I understand and agree that I must provide AAMC with evidence of a Physician s signature indicated on the immunization requirements form before beginning with the Program. 3. Program Requirements: The intern/volunteer must comply with the following requirements: a. Notify the Volunteer Coordinator ( ) if unable to attend a scheduled shift b. Arrive on time for every scheduled shift or activity and must stay until its completion c. Wear the proper uniform and ID badge while participating in the Program d. Retain any documentation of working hours provided at the end of the Program, and understand that the Volunteer Office may not be able to provide this documentation at a future date. e. Comply with all rules, regulations and policies of AAMC. 4. Background Checks: I understand and agree that, as a condition of being selected as a volunteer at Anne Arundel Medical Center, AAMC will conduct a criminal background check. My signature below constitutes my authorization for AAMC or its agents to check my background. I waive and release AAMC and its agents from any and all claims I may otherwise have with respect to any such criminal background check. Background checks are not completed on minors. 5. Legal Guardians for Minor Intern/Volunteer: I attest that I am the parent or legal guardian of the intern/volunteer and that I am authorized to sign this Agreement on behalf of the intern/volunteer. I hereby grant permission for the intern/volunteer to participate fully in the Program. Furthermore, I hereby authorize AAMC to provide emergency medical care that may become necessary during the intern/volunteer s participation in the Program, and I assume the responsibility for costs of care. If volunteer/intern is under 18 year of age, the signature of a parent or guardian is required. I understand that this is an application for and not a commitment or promise of volunteer opportunity. It is the policy of the Volunteer Office of Anne Arundel Medical Center to provide equal opportunities without regard to race, religion, national origin, gender, sexual preference, age, or disability. Volunteer Printed Name: Volunteer Signature: Date: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

4 Anne Arundel Medical Center - Student Volunteer Immunizations Form Immunizations must be complete upon application submission in order to be selected to volunteer Student Name: Date of Birth: / / REQUIRED IMMUNIZATIONS Test Dates Given & Results Notes Tuberculosis Test (must be within the last 12 months) Chest X-Ray (only required if TB test is positive) MMR Vaccine Series or Titer Varicella Vaccine Series or Titer Flu Vaccine (current year) Tdap (must be within the last 10 years) Hepatitis B Vaccine Series or Titer Meningococcal Vaccine TB Test Given: / / Read: / / MM: Chest X-Ray (MM/DD/YY): Date Taken: / / 2.) / / Titer: Date Drawn: / / 2.) / / Titer: Date Drawn: / / 2.) / / 3.) / / Titer: Date Drawn: / / Required for all volunteers Required for all volunteers Required for all volunteers Required yearly October-March for all volunteers *Additionally required for clinical environments *Additionally required for clinical environments *Additionally required for participation in the Emergency Department HEALTH CARE PROVIDER SIGNATURE (Dr., Nurse, NP, PA, DO) This form will not be accepted if not signed by a health care provider. Printed Name: Phone: Address: Signature: Date Completed: / /

5 HIGH SCHOOL STUDENT VOLUNTEER RECOMMENDATION FORM (AT LEAST ONE RECOMMENDATION REQUIRED FOR HIGH SCHOOL STUDENTS), who is applying to Anne Arundel Medical Center Volunteer Program, has the following attributes that demonstrates his/her ability to be a good team member: Describe the reliability and willingness of the applicant. In your opinion, will he/she be able to commit to volunteering at a hospital? Has the applicant maintained regular school attendance? Yes No Volunteers who work in our hospital tend to have frequent contact with very sick people and their families. In light of his/her personality and current level of maturity, do you feel comfortable recommending the applicant for placement in a hospital setting? Why or Why not? Teacher, Guidance Counselor, or Principal Signature: Printed Name: Date: Title: Phone Number: School Name:

6 (PLEASE KEEP THIS PAGE FOR FUTURE REFERENCE) Dedication: We require a minimum of one 3-hour block of time per week to volunteer at your assigned area. Assignments are based upon strength of application and availability. No assigned areas are guaranteed. Requirements: High School Students: Must return attached High School Student Volunteer Recommendation Form (to be completed by a teacher, guidance counselor, or principle). College Students: must be in the process of obtaining a two or four year degree. Complete and return application and all applicable forms by the deadline. Volunteers must show initiative as well as be compassionate, team players, and ready to commit to date and time scheduled. Immunizations: Immunizations are a requirement of the healthcare environment. Please turn in your form with your application. Only students who have complete immunization records will be selected. If you are in process of a shot series, please turn in what you have and we will collect additional documentation if selected. Sample volunteer placements and duties: Wayfinding Information Desks Clinical Floors Radiology Front Desk Emergency Room Marketing/Communications Joint and Spine Outpatient Rehabilitation Pediatric ER Greeting and assisting patients with navigating the hospital, answering questions, providing excellent customer service to all patients and visitors. Answering phones, providing information about the hospital and department locations to patients and visitors, clerical duties. Keep hallway clear of wheelchairs and stretchers, communicate problems, questions or patient concerns, transport patients for testing, visit patients often and offer assistance to them or their families. Provide linens and personal supplies to patients, set up food trays. Front desk greeting patients, clerical work, assistant the techs with gathering paperwork and escorting patients. Clerical, stock rooms, monitor doors, time stamp triage forms as patients arrive, answer nurse call button, provide pink badges, etc. social media, branding within the hospital and delivering communications, etc. Assist physical therapists with group therapy, set up and move tables for lunch, assist with serving patients in common areas, obtain supplies from distribution. Putting new patient files together, filing, scanning and assisting with EPIC transition. Work at the front desk answering telephone calls, cleaning toys, and assisting Child/Life if needed. Follow-up: You will be contacted by the Volunteer Services office if you have been selected for placement at Anne Arundel Medical Center. Questions or concerns? Please contact Nikki Simmons, Volunteer Coordinator, at nsimmons@aahs.org. Completed packets can be mailed or faxed to: Anne Arundel Medical Center Foundation, Attn: Nikki Simmons 2000 Medical Parkway, Belcher Pavilion - Suite 604, Annapolis, MD Fax: