Dear Prospective Junior Volunteer,

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1 Dear Prospective unior Volunteer, Thank you for expressing interest in the unior Volunteer Program at Christ Hospital. The unior Volunteer Program is an excellent opportunity for students aged 14 and above to learn valuable skills while providing an important service to their community. Christ Hospital depends upon its team of dedicated volunteers in order to provide quality, compassionate care to the citizens of Hudson County. Our unior Volunteers are an important part of that team. Whether you are interested in assisting patients and families or in supporting our administrative staff, the is sure to have a volunteer service opportunity that is just right for you. Enclosed in this packet are the application materials needed to process you as a unior Volunteer. Please complete all required forms and return them to the. Please be sure to include the following with your unior Volunteer application: unior Volunteer Disclosure Form Two forms of ID (picture id & social security card) unior Emergency Medical Treatment unior Volunteer Medical Release Form signed by your doctor Two letters of recommendation from teachers/guidance counselor 250 word essay on Why you want to volunteer and what do you expect to get out of this experience Please note: the unior Volunteer Medical Treatment form needs to be signed by your doctor before being returned to us. We also require all our unior Volunteers to have a parent or guardian sign the enclosed forms where indicated. After we receive your application materials we will contact you to schedule you for one of our volunteer orientation sessions. All volunteers must complete orientation before starting work. Please mail the completed application forms to: Christ Hospital If you have any questions, please contact the at. Thank you in advance for offering us your time and talent. We look forward to working with you! Christ Hospital

2 unior Volunteer Application Contact Information Address Availability During which hours are you available for volunteer assignments? Sunday Monday Tuesday Wednesday Thursday Friday Saturday 8:30-12:00 8:30 12:00 8:30 12:00 8:30 12:00 8:30 12:00 1:00 5:00 1:00 5:00 1:00 5:00 1:00 5:00 1:00 5:00 Note: the majority of volunteer positions are during regular business hours (Monday to Friday, 8am to 5pm) Interests Tell us in which areas you are interested in volunteering Patient/Family Hospitality Administrative/Clerical Volunteer Pool/Float Special Skills or Qualifications Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies and any foreign languages spoken.

3 Previous Volunteer Experience Summarize your previous volunteer experience. Person to Notify in Case of Emergency Cell Phone Address Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. (printed) Signature Parent/Guardian Permission and Signature I realize the need for my son/daughter to respect and obey the rules, regulations, policies and procedures as set forth by Christ Hospital and the Department of Volunteer Services and to uphold its code of ethics. I therefore grant permission for my son/daughter to participate in this program and fully understand and assume the responsibility to ensure that he/she will comply with the requirements and standards and will maintain a courteous and professional disposition. I further agree to review my son/daughter s assignment and schedule and will oversee his/her attendance. Parent/Guardian (printed) Signature Our Policy It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual orientation, age, or disability. Thank you for completing this application form and for your interest in volunteering with us.

4 unior Volunteer Disclosure Form Consent to Background Check In connection with my application for volunteer services with you, I understand that investigative background inquiries are to be made concerning myself including consumer reports, investigative consumer reports, criminal, driving and other reports. These reports may include information as to my character, credit worthiness, general reputation, personal characteristics, mode of living, work habits, performance and experience, along with reasons for termination of past employment from previous employers. I have a right to request disclosure of the nature and scope of the report, which involves personal interviews with sources such as neighbors, friends or associates. I authorize, without reservation, any party or agency contacted by this employer or its agent to furnish the above mentioned information: Print Full Social Security Number of Birth Driver s License Number Applicant s Signature Parent/Guardian Signature State History Please list all previous names used (if any) Former s used Please list the cities or towns you have lived in covering the past 7 years. Use additional pages if necessary. s s Have you ever been convicted of a crime (other than a traffic violation)? Yes / No If yes, please explain on attached sheet. Education High School University/College Other School/Training City, State City, State City, State References (other than family members) Employer (if any) School Reference Personal Reference Phone Phone Phone

5 unior Emergency Medical Treatment Volunteer Contact Information Social Security Number Christ Hospital has different legal obligations to volunteers. The hospital is neither responsible nor liable for any injury sustained to a volunteer while the volunteer is on duty. The law requires that parental permission be obtained for procedures on minors. In the event your son/daughter becomes ill or injured while on duty as a volunteer, he/she will be taken immediately to the ER for evaluation and treatment in accordance with your instructions. Every effort will be made to contact a parent or guardian. Please be advised, should the attending physician on duty deem it necessary, treatment will begin immediately in cases such as the following: 1. Severe loss of blood 2. Convulsions 3. Unconsciousness 4. Respiratory Obstruction 5. Severe burns Consent For Treatment I hereby authorize Christ Hospital and /or such assistants as may be selected to diagnose and treat my son/daughter should he/she become ill or injured while on duty as a volunteer. Parent or Guardian Parent or Guardian Signature Person to Notify in Case of Emergency Address

6 unior Volunteer Medical Release Contact Information of Birth Social Security Number All applicants to Christ Hospital s must have clearance from a physician that indicates that he or she has no physical or emotional impairments that might interfere with volunteer work at Christ Hospital. In addition to this medical clearance, all volunteers will be required to take a blood test to check for immunity to Measles, Rubella and Varicella and will also be required to take a TB test. These blood tests will be performed here at the hospital at no charge to you. Please return this form signed by your personal physician along with your application. Physician s Release (Required) In compliance with the New ersey State Health Code, I have recorded a physical examination and medical history for and have found him/her to be free of any physical or emotional impairment which is of potential risk to patients or staff, or which might interfere with the performance of his/her duties. Please state limitations, if any: Signature of Physician Print Address

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