Application for Summer Junior Volunteer Program (15-17yrs)
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- Garey French
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1 Application for Summer Junior Volunteer Program (15-17yrs) This Packet Includes: Application Personal Essay Recommendation Form (Must have at least 1 but may have 2 recommendations completed by a teacher or a counselor) Please complete all required forms for your packet to be considered. The deadline to submit your packet is: THURSDAY, FEBRUARY 25 BY NOON No exceptions 50 positions are available To submit your packet please to: volunteers@chla.usc.edu IS THE ONLY MEANS BY WHICH WE WILL ACCEPT YOUR APPLICATION. Applicants will be notified by mail beginning March 7, 2016
2 Children s Hospital Los Angeles Application for Summer Junior Volunteer Program (15-17 yrs) PLEASE TYPE DATE First Name Middle Name or Initial Last Name Street Address City Zip Social Security Number Birthday (Month/ Date/ Year) Gender (Please mark) M F Home Phone Driver License Number and State (if applicable) Mobile Phone Have you ever been convicted of a crime (other than a minor traffic violation)? If yes, please explain No Yes Name of High School Grade Level Last Day of School First Day of School Previous or current volunteer experience Emergency Contact Relationship to the above Phone Days & Shifts are as follows: Monday through Friday AM 9:00 12:30 or PM 1:00 4:30 Volunteers must commit to 3 shifts per week Please indicate your availability below MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY AM PM AM PM AM PM AM PM AM PM
3 Volunteer Agreement and Certification of Information Believing that Children s Hospital Los Angeles has need of my services as a volunteer, I agree: To hold as absolutely confidential all information which I may obtain directly or indirectly concerning patients, parents, doctors, or personnel, and will not seek confidential information in regard to a patient. To commit to 3 times a week for 3.5 hrs a day in a solid block of time from June 20 to August 5, 2016 and to attend the General Orientation on Saturday, June 18, That my services are donated to Children s Hospital Los Angeles without contemplation of compensation, or future employment, and given with humanitarian or charitable reasons. I certify that the answers given by me to the foregoing questions and statements are true, correct, and without omissions. I authorize Children s Hospital Los Angeles to investigate and/ or verify the foregoing information and any other information, which might assist them in determining my qualifications for volunteering. I release Children s Hospital Los Angeles and my former employers, and all others from any liability from damage, which may result from such investigation, if, upon investigation, anything contained in this application is found to be untrue. I further agree to conform to the rules and regulations of this facility. I understand that my volunteer status at Children s Hospital Los Angeles can be terminated at any time for failure to comply with the policies, rules, and regulations of the Hospital including those of the volunteer department; for absences without notification; for reasons of unsatisfactory attitude, work or appearance; and for any other circumstances which, in the judgment of the Hospital, would make my continued service as a volunteer contrary to the best interests of the Hospital. I also understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility. ANY PERSON WHO INTENTIONALLY GIVES MISLEADING OR FALSE INFORMATION WILL BE SUBJECT TO IMMEDIATE TERMINATION. Print Name: Date: Signature: JUNIOR VOLUNTEER PARENT/GUARDIAN CONSENT FORM I authorize my daughter son age to participate in the Junior Volunteer Program at Children s Hospital Los Angeles, and to engage in such volunteer activities as may be assigned by the Manager, or a designated representative. I give my permission to the Hospital for the administration of any minor treatment, should it be deemed necessary. I release Children s Hospital Los Angeles from any claim or liability for any injury or illness resulting to said minor, not occasioned by any fault or neglect on the part of the Hospital, while participating in such volunteer activities. Signed:
4 Personal Essay: For your application to be considered, you must complete a personal essay. The essay must be one full page, double-spaced and typed in size 12 Times New Roman Font. In recognizing your passion for children, please tell us why you should be considered for a volunteer position at Children s Hospital Los Angeles.
5 Children s Hospital Los Angeles Summer Junior Volunteer Program RECOMMENDATION FORM INSTRUCTIONS Dear Teachers And Counselors, Thank you for your willingness to complete the recommendation on behalf of this candidate to volunteer for CHLA. Our Summer Junior Volunteer Program offers mature teens an opportunity to be of service to our patients, families and staff of Children s Hospital Los Angeles. Our decisions on who to accept are based on matching the needs of our Hospital. We rely on recommendations, such as yours, in helping us identify those who will both match and benefit from our program. Here are some of the criteria we are looking for in a candidate: Has a strong need to be of service Demonstrates an ability to make the most of learning opportunities Is mature, self-directed Is intellectually capable, although academic performance per se is not a factor in admission Has demonstrated behaviors suggestive of the desire to make a positive contribution (i.e. volunteering, tutoring) Demonstrates regard for others, empathy, natural courtesy in daily interactions Since this recommendation will be returned to the student, you may call us at if you have reservations about your recommendation. Please print clearly or type. A prompt reply is appreciated. Please return the completed forms directly to the applicant. Do not send directly to Children s Hospital Los Angeles. Thank you, Volunteer Resources Department
6 Children s Hospital Los Angeles Summer Junior Volunteer Program RECOMMENDATION FORM *Please refer to the Recommendation Instructions for guidance. NAME OF APPLICANT 1. How long have you known the applicant and what is your relationship? 2. Why do you think the applicant is applying to volunteer? 3. Based on the criteria, please identify and or describe the behaviors the applicant consistently demonstrates. 4. Identify and or describe behaviors demonstrated that need improvement? 5. Please comment about the applicant s potential for future professional success in a healthcare field. 6. Additional comments. 7. Summary Evaluation. Using the chart below, please rate the applicant relative to others you have known in a similar capacity.
7 OUTSTANDING EXCELLENT GOOD FAIR POOR NOT OBSERVED Motivation to learn Interest in well-being of others Intellectual potential Leadership potential Judgment Maturity Self- Directed Communication skills: oral Communication skills: written Organizational skills Ability to analyze a problem and formulate a solution Relationship/Collaborative ability to work with others Ability to work independently General knowledge level Motivation for pursuing a career in healthcare Please Print Name Professional Title School Phone Number Full Address Date Please return this form to the applicant for inclusion in their application packet. Thank you.
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