Volunteer Application

Thank you for your interest in volunteer opportunities here at Magee Rehabilitation Hospital. To apply for volunteer placement, you will need to commit to volunteering a minimum of 100 hours and: 1) Complete the attached application, including the Volunteer Information Release Form. 2) Provide us with proof that you have a current flu vaccination (during current flu season, September April). Magee Rehabilitation Hospital is requiring all volunteers to provide an annual proof of the influenza vaccination. You are required to get the flu vaccination annually, at your own expense. If you do not have a current flu vaccination, you will not be permitted to volunteer at Magee. This vaccination needs to be updated annually for all volunteers. 3) Provide us with proof of a negative tuberculin (PPD) test result dated within the past six months. Ask your doctor for a note, and fax this to 215-587-3447. If you do not have one, Magee may be able to provide the PPD test for you. This test needs to be completed annually for all active volunteers. 4) If you are a student applying for a volunteer position in Physical Therapy, Occupational Therapy, Therapeutic Recreation, Nursing, or Speech Therapy, write a letter, including your name, address and telephone number, a brief statement of your reasons for wishing to volunteer at Magee, a photocopy of your valid student ID, related volunteer or paid experience, and the days and hours you are available to volunteer. Please note there is a waiting list for these positions. * If you are a student, under 18 years of age, you must complete the permission form and have it signed by your parent or guardian. 5) Include your resume, if you have one. 6) Send all of these materials: o By FAX to Volunteer Department at 215-587-3447 o Or scan all pages and email to volunteer@mageerehab.org o Or mail to: Volunteer Department Magee Rehabilitation 1513 Race Street Philadelphia, PA 19102 Magee Rehabilitation Hospital performs background checks and child abuse clearances on all volunteers once a position is determined for the volunteer. All interested volunteers must attend a mandatory orientation session at the hospital prior to placement. Thank you for your interest in volunteering at Magee Rehabilitation Hospital. 1

Application Date: / / First Name Last Name Home Address City State Zip Home # Cell # Work # Email Birthday: Month Day Year Optional, for demographic reporting purposes only: Gender: Race: Years completed in school: High School/GED College Other Occupation Employer * If currently enrolled in school, please list school Does your employer provide matching gifts or donations for volunteer service? Please submit gift form to Community Programs Coordinator. Circle answer. Yes No Not sure, but will check Other Please indicate any accommodations you require to volunteer Name of Friend or Relative for Magee to Notify in an Emergency: Home # Cell # Relationship FOR VOLUNTEER OFFICE USE ONLY: NOTES: DATE REC D: INFO SES: BC TO HR: ORIENTATION: START DATE: DEPT: SUPERVISOR: DATA ENTRY: HOURS DAYS 2

Last Name What are your hobbies and interests? Where have you volunteered before? What did you do there? How did you learn about Magee's Volunteer Services? Why do you want to volunteer at Magee? References Please provide the names, addresses and phone numbers of two persons not related to you. We will be contacting them. Name Phone # Address Email Name Phone # Address Email 3

When are you available to volunteer? * Please check all that are appropriate. Sunday Monday Tuesday Wednesday Thursday Friday Saturday 6-10 AM Therapy Hours 9 AM Noon M-F 10 AM - 2 PM Therapy Hours 1-4 PM M-F 2-6 PM 5-8 PM Last Name Anytime I can work the following specific hours: POSITION YOU ARE APPLYING TO: HOURS PER WEEK YOU ARE AVAILABLE: HOURS PER SHIFT: If volunteering for a position in Physical Therapy, Occupational Therapy, Therapeutic Recreation, Nursing, or Speech Therapy, please complete the following: Total number of hours to complete: Date hours need to be completed by: Setting (check all that apply): In-Patient at 1513 Race Street, Philadelphia Out-Patient at Riverfront, 1500 Columbus Boulevard, Phila. Please circle the holidays/events on which you are available to volunteer: New Year's Day Martin Luther King, Jr. Day Memorial Day Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Day Christmas Day Patient voter Registration in July and absentee ballots in October Last Name 4

Volunteer Preference Survey: Please complete with your level of interest of activities you like to do. This will help us to place you in a volunteer position at the hospital. Activity Very Often Sometimes Never Work with people who are ill or injured Data entry and typing Filing records Research and analyze data Search the internet Research at the library Organize books and DVD's Talk with people or interview Lead discussions/speak to a group Run meetings Teach or tutor Work on the phone Help plan events Help with fundraisers by selling items Work a cash register Cooking and kitchen activities Help distribute meals to patients Enjoy sporting events Gardening and interest in plants Read aloud 5

Last Name Activity Very Often Sometimes Never Write creatively Draw Make arts and crafts Play games (circle: chess, poker, card games, board games, ping pong, pool, Wii) Watch movies Entertain audiences Sing Karaoke/DJ Play music (Instrument(s): ) What computer programs/platforms can you use? (Check all that apply) Microsoft Word Microsoft Excel Microsoft Access Microsoft Publisher Constant Contact or other HTML email program Digital Photography Social Networking - Facebook, Twitter, etc. Adobe Suite or graphic design software HTML and web design Other: Additional Notes: 6

CONSENT FORM FOR YOUTH VOLUNTEER PROGRAM TO: Parent(s) or Guardian of FROM: Community Programs Coordinator, Magee Rehabilitation In order for your child to become a volunteer at Magee Rehabilitation, we must receive your written consent. Please read and sign the attached form, and, if you have questions, or concerns, feel free to call me at 215 587-3140. We appreciate your child s interest in volunteering to assist our patients and staff. Thank you. I give my permission for to volunteer at Magee Rehabilitation I understand that s/he: o will receive orientation prior to beginning volunteer service at Magee. o will work out a weekly schedule with the Community Programs Coordinator. o will be expected to comply with all guidelines which apply to Magee volunteers and to honor his/her volunteer commitment. I also understand that, should s/he fail to comply with the guidelines or fail to keep his/her commitment without giving adequate advance notice, s/he will be on probation and will have his/her volunteer services re-evaluated by the Community Programs Coordinator. (Parent/Guardian s Signature & Date) (Your relationship to the volunteer) Please have your child return this form with his/her volunteer application. Thank you. 7

VOLUNTEER INFORMATION RELEASE FORM Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act, the Drivers Privacy Protection Act and all other applicable federal, state, and local laws, I hereby authorize and permit CSS Test, Inc., to obtain a consumer report and/or an investigative consumer report which may include the following: 1. Records concerning any driving history (if driving as a volunteer), criminal history, child clearances and civil record history. 2. Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records. 3. My employment records. I understand that an investigative consumer report may include information as to my character, general reputation, personal characteristics, and mode of living, which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I agree that a copy of this authorization has the same effect as an original. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as from any liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification and written notification to them. I hereby authorize CSS Test, Inc. to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my application. This authorization shall remain in effect for the full duration of my time associated with Magee Rehabilitation. *****PLEASE PRINT AND COMPLETE ALL FIELDS***** Full Name Signature Today s Date / / Date of Birth / / Street Address Apt# City State Zip Social Security # - - Driver s License # State of Issue 8