Dear Prospective Teen Volunteer:

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1 Dear Prospective Teen Volunteer: Thank you for your interest in the Delnor Hospital Volunteer Program. We have an active program with over 550 men, women and teens contributing over 55,000 hours of volunteer service each year at our hospital, Hi-Hat Resale Shop and other Cadence Health affiliates. Where you are placed within the Cadence Health volunteer program depends on the times and days you are available and your areas of interest. We make every effort to place volunteers in an area they will find most rewarding. Our goal is to find the best fit between our volunteers and their specific assignment, so your responses to the questions on the enclosed application are very important. Please make every effort to answer the questions completely and accurately. When you have completed and signed the application forms, please fax them to , or them to or mail them to Delnor Hospital, Volunteer Services, 300 Randall Road, Geneva, IL Once your application is received, we will or mail you a list of volunteer orientation sessions. Please RSVP for the session that works best for your schedule. Delnor Hospital teen volunteers must attend volunteer orientation, complete the health screening for tuberculosis (TB) and measles, mumps and rubella (MMR), as well as complete all scheduled training in order to formally start as a Cadence Health hospital volunteer. I am thrilled that you are considering sharing your valuable time with Cadence Health as a volunteer. I look forward to meeting you soon. If you have any questions, feel free to call the volunteer office at TTY for the hearing impaired Sincerely, Joy Rosenberg Manager, Volunteer Services

2 Placement of a volunteer depends on availability of positions and interview. Volunteer applications will be considered current for 90 days. Please complete all the enclosed forms and return them to the Delnor Hospital, Volunteer Services, 300 Randall Road, Geneva, IL or by fax at Signed and scanned applications may be ed to PLEASE PRINT: Delnor Hospital Volunteer Application Check one: I am an Adult or a Teen Applicant Last Name: First: Address: City: Zip: Home Phone: Cell Phone: Address: Are you over 18 years of age or graduated from High School? [ ] Yes [ ] No Education: (Circle last year completed) High School College Emergency Contact Information: 1) Name: Phone: 2) Name: Phone: Are you currently employed? [ ] Yes [ ] No If yes, what time of day do you work? Work Phone: Current/last place of employment: What days are you available to volunteer? (Check all that apply): [ ] Sun [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat What times are you available to volunteer? (Check all that apply): [ ] Early Morning [ ] Morning [ ] Afternoon [ ] Evening 5 8 am 8 am Noon Noon 4 pm 4 8 pm Do you have a valid driver s license? [ ] Yes [ ] No Have you ever been convicted of a crime? [ ] Yes [ ] No

3 Tell us about yourself 1. What do you like to do? 2. Will you need time off from volunteering? 3. Have you ever volunteered before? [ ] Yes. If yes, what did you do? [ ] No 4. What did you enjoy most about volunteering? 5. What did you like least about volunteering? 6. Do you like to work on your own or with a partner and why? 7. Why did you pick Delnor Hospital? 8. Why is right now a good time for you to volunteer? 9. List one of your greatest accomplishments. 10. What do you hope to gain from this experience? 11. What do you see yourself doing as a volunteer at Delnor Hospital? 12. Is there anything you would like to tell us about yourself that would help us find the best volunteer position for you? (Physical limitations, medications, etc.) 13. Are you flexible about what kind of volunteer work you do? 14. Are you interested in working with: [ ] Patient or public contact [ ] Clerical or no public contact [ ] No preference Volunteer Signature Date

4 Volunteer Responsibilities Proper uniform, including name badge, must be worn at all times while you are on duty, including training. Please refrain from wearing any perfumes, colognes or fragrances. Wear closed toe shoes. Professional Appearance: This includes black, khaki or navy slacks or skirt; white or off-white shirt and volunteer vest or smock for hospital based volunteers. You must notify the office if you are unable to present for your service. o CDH Volunteers o CDH Gift Shop Volunteers o Delnor Volunteers o Delnor Gift Shop Volunteers o Off campus volunteers please contact your supervisor For planned absences, please arrange for a substitute in advance and inform the volunteer office and your department supervisor. Volunteers must complete a minimum of 50 hours per year of volunteer service. All medical requirements must be completed prior to your initial training. This includes proof of measles, mumps, rubella and varicella vaccines (MMR and Varicella) as well as completed tuberculosis (TB) testing. This process is handled by Cadence Employee Health offices on either the Delnor Hospital or CDH campus. Volunteer Services staff must be notified of any unusual incidents that occur while you are volunteering. If you are unable to reach us please call: o CDH Nursing supervisor extension o Delnor Hospital Nursing supervisor extension In the case of an on-campus emergency immediately call extension for assistance Should you require medical attention please know that you are not covered under the hospital s medical insurance or worker s compensation programs. Your parents (if you are under 18) or you will be responsible for medical costs associated with any care or treatment that is required. Should you have any questions about any of our volunteer procedures please call: o CDH o Delnor o TTY for the hearing impaired

5 Cadence Health Volunteer Agreement As a Cadence Health volunteer, I agree that: 1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, or personnel and not seek to obtain confidential information from a patient, except as it relates to my volunteer assignment. An accidental or intentional release of confidential information will lead to termination of my volunteer relationship with Cadence Health. There may be legal penalties for anyone who discloses confidential information. 2. I shall be punctual and conscientious, conduct myself with dignity, courtesy and with consideration of others and endeavor to make my performance professional in quality. 3. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept. 4. I shall, at all times, uphold the values of Cadence Health and adhere to all safety and security policies and procedures. 5. I understand that the scope of my volunteer relationship with Cadence Health is limited to my volunteer position and is not a position of employment. I expect no compensation in return for services provided while I am volunteering in a Cadence Health facility. I understand that no benefits traditionally associated with employment are offered. 6. I understand that the Cadence Health Volunteer Services reserves the right to terminate my volunteer status as a result of: failure to comply with hospital policies, rules and regulations absences without prior notification unsatisfactory attitude, behavior or appearance 7. I understand that I will be properly trained in my volunteer position and after training is completed, my competency may be subject to evaluation. If there is something that I do not understand about the services I am providing after training is completed, I will contact the Volunteer Services Manager or Director for guidance. 8. I understand that I will have a specific dress code to follow as a volunteer. 9. I will take any concern or criticism to the Volunteer Services Manager or Director. 10. I understand that if I am injured or require medical attention while I am volunteering, I or my parents (if I am a minor) will be responsible for the cost of related medical care and treatment. I also understand that I am not covered under the hospital s medical insurance or worker s compensation programs. I have read the above conditions and I agree to them. Volunteer Signature Date

6 COUNSELOR/TEACHER REFERENCE DELNOR HOSPITAL TEEN VOLUNTEER PROGRAM has recently applied to be a teen volunteer at Delnor Hospital. A Teen Volunteer needs a reference from a teacher or other adult (someone other than a relative).we would appreciate you taking the time to answer the following questions. The information will be treated in the strictest confidence. If you have any questions regarding the information requested, please contact Volunteer Services at TTY for the hearing impaired We welcome students and are concerned that their schoolwork might suffer as a result of volunteering. Do you think that the applicant s schoolwork will be adversely affected if she/he volunteers during nonschool hours? Please comment. Would you recommend the applicant as dependable, qualified, responsible and able to demonstrate respect and strong moral character needed for the position of a Teen Volunteer? How long have you known the applicant? In what capacity have you known the applicant? Additional comments: Non-family Adult /Teacher Signature Date Phone Number Please mail to: Delnor Hospital Volunteer Services 300 Randall Road Geneva, IL Fax:

7 TEEN PARENT/GUARDIAN CONSENT FORM My (our) daughter/son, has my (our) consent to serve as a teen volunteer at Delnor Hospital. I understand that the decision to volunteer is a serious one. Therefore, I will support my son/daughter in his/her volunteer commitment. I will encourage him/her to use this volunteer experience as an opportunity to learn and grow. I will facilitate my son s/daughter s volunteer experience and realize that students are strongly encouraged to be personally responsible for their volunteer schedules, appointments and commitments. Repeated absences without notification will result in dismissal from the Delnor Teen Volunteer Program. I (we) have read the application agreement and will share in the responsibility of this commitment. I (we) also give my (our) consent for my (our) daughter/son to receive necessary TB (Mantoux) testing. I (we) understand that should my child be injured or require medical attention while he/she is volunteering, that I (we) will be responsible for the cost of related medical care and treatment. My son/daughter is not covered under the hospital s health or worker s compensation insurance plans. I understand that my child will receive a copy of the attached responsibility form at the time of orientation and/or interview. PLEASE CALL CADENCE EMPLOYEE HEALTH AT WITH ANY QUESTIONS OR CONCERNS. TTY FOR THE HEARING IMPAIRED PLEASE NOTE THAT A COPY OF TEEN S MMR AND VARICELLA IMMUNIZATIONS MUST BE PRESENTED AT THE EMPLOYEE HEALTH OFFICE AT THE TIME OF TB TESTING. DO NOT SUBMIT WITH APPLICATION. Parent/Guardian Signature Parent/Guardian Printed Name Date

8 TEEN VOLUNTEER CONSENT FOR TREATMENT INSTRUCTIONS Cadence Health feels that it is very important to begin treatment of injuries or diseases as soon as possible. In the event your child is brought to our emergency department and we are unable to contact you, this form will help us begin treatment and diagnostic testing. The emergency staff will still attempt to contact you to get personal permission to treat. Read the entire form and complete all areas. Place your family s last name at the top of the consent form. Relative/friend should be someone you feel could give us more information about your child or tell us how to get in contact with you. If you require more room to write allergies or special information, please use the back of this form. Family s Last Name: Child s First Name Middle Initial Date of Birth Allergies or Special Information Parent/Guardian Name(s): Street Address: City, State, Zip: Relative/Friend to contact: Family Physician: Home Phone: Cell Phone: Work Phone: Phone Number: Phone Number: I (we) understand that should my child be injured or require medical attention while he/she is volunteering, that I (we) will be responsible for the cost of related medical care and treatment. My son/daughter is not covered under the hospital s health or worker s compensation insurance plans. Parent/Guardian Signature Date

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