Prince William Medical Center Haymarket Medical Center Teen Volunteer 2016 Summer Program Application Form (Applicants: Must have finished at least the sophomore year of high school by summer 2016) Deadline for application: Friday, April 29, 2016 at Midnight; USPS delivery must be postmarked on or before April 29, 2016. Personal Information (Please Print Clearly) Name: E-Mail: (First Name, Middle Initial, Last Name) Address: Number/Street Apt. City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Birthdate: School you attend: Grade level as of Fall 2016: Graduation year: 20 Current G.P.A.: Last four digits of your Social Security Number: Application Requirements Completed Application: Form(s) with all needed personal information Two references may only be completed by anyone such as: clergy, employers, teachers etc. anyone who is not a relative or a resident in your home - When your references have completed the reference form that you have provided to them, they may be faxed, mailed (see below) or brought in to the volunteer office. Novant Health Prince William Medical Center Volunteer Services, Teen coordinator 8700 Sudley Road Manassas, VA 20110 FAX: 703.369.8728 - It is your responsibility to provide the address and fax number to your references A copy of your latest report card Medical Immunization Records showing that all your immunizations are up to date. Responses to the 2 questions on the next page Page 1 of 7
Tentative acceptance into the program is based on the order of the date that the complete application packets are received. A complete packet includes the following: 1. complete application form 2. both references 3. responses to both questions (see below) 4. copy of most recent report card 5. medical immunization records It is also your responsibility to follow up to make sure your file is complete. Please call 703.369.8173 to check on your status Complete application to the program does not guarantee acceptance into the program; you must attend all mandatory meetings. PLEASE ANSWER QUESTIONS BELOW Questions (to be typed answers with your name included on the paper) 1. Why do you wish to volunteer at a hospital? 2. What makes you a good candidate for volunteering at a hospital? When your application packet is complete you will be formally invited to the Parent/Teen Information Meeting which both you and a parent must attend on either Wednesday, May 17 from 6:00 p.m. until 8:00 p.m. OR Thursday, May 19 from 6:00 p.m. until 8:00 p.m. Mandatory Teen Interviews are scheduled at the Parent/Teen Information Meeting. PARENT/TEEN INFORMATION MEETING: Mandatory Meetings May 17 th from 6 to 8 p.m. OR May 19 th from 6 to 8 p.m. GROUP INTERVIEWS: May 25, June 1, 8, 15, 22; 3 to 4 or 4 to 5 p.m. HOSPITAL TEEN ORIENTATION: July 11, 25 or August 8, 9 to 3 p.m. Page 2 of 7
Please rank all six sessions below in order of preference from 1 to 6. (1 being first choice - 6 being last choice) Morning: Afternoon: Morning: Afternoon: Morning: Afternoon: Session 1 July 11 through July 22 July 11 8:45 am until 3:00 pm (orientation, training and lunch) July 12 through July 21 8:45 am until 12:00 noon July 22 10:00 am until 1:30 pm (including lunch) July 11 8:45 am until 3:00 pm (orientation, training and lunch) July 12 through July 21 11:45 am until 3:00 pm July 22 10:00 am until 1:30 pm (including lunch) Session 2 July 25 through August 5 July 25 8:45 am until 3:00 pm (orientation, training and lunch) July 26 through August 4 8:45 am until 12:00 noon August 5 10:00 am until 1:30 pm (including lunch) July 25 8:45 am until 3:00 pm (orientation, training and lunch) July 26 through August 4 11:45 am until 3:00 pm August 5 10:00 am until 1:30 pm (including lunch) Session 3 August 8 through August 19 August 8 8:45 am until 3:00 pm (orientation, training and lunch) August 9 through August 18 8:45 am until 12:00 noon August 19 10:00 am until 1:30 pm (including lunch) August 8 8:45 am until 3:00 pm (orientation, training and lunch) August 9 through August 18 11:45am until 3:00 pm August 19 10:00 am until 1:30 pm (including lunch) By signing this application, the teen certifies that all of the information is true and accurate and that the teen is committing to adhere to all program requirements and rules including but not limited to dress, acceptance of assignment, and any other rules which may be necessary for the smooth operation of the program. Teen Signature: Date: PRINTED Teen Name: By signing this application, the parent/legal guardian certifies that all of the information is true and accurate, that the teen will adhere to all program requirements and rules (including but not limited to dress, acceptance of assignment, and any other rules which may be necessary for the smooth operation of the program), and gives permission for his/her son/daughter to participate in the teen volunteer program at Novant Health Prince William Medical Center. Legal Guardian or Parent Signature: Date: Page 3 of 7
PRINTED Legal Guardian or Parent Name: Employee health: Teen Volunteer Program Immunization History Name: Address: Phone: DOB: TO THE PHYSICIAN: Please fill in dates. Yellow highlights are mandatory TB Skin Test 1) 2) BAMT Blood Assay Results MMR Vaccine 1) 2) Rubeola Vaccine 1) 2) Rubeola Titer Results Mumps Vaccine 1) 2) Mumps Titer Results Rubella Vaccine 1) 2) Rubella Titer Results (German Measles) Chicken Pox 1) 2) Varicella Titer Results (Varicella) Hep B (optional) 1) 2) 3) Results Oral Polio 1) 2) 3) 4) HIB 1) 2) 3) 4) DTP/TD 1) 2) 3) 4) 5) 6) Has this patient been exposed to active Tuberculosis? YES / NO Patient is cleared to participate in the teen volunteer program. YES / NO, if restrictions please list: MD Signature: Official Date Stamp: Page 4 of 7
Prince William Medical Center Haymarket Medical Center Volunteer Emergency Contact Form For: Name of Volunteer / Please Print #1 Name: Home Phone Number Work Phone Number: Cell Phone Number: Relationship: #2 Name: Home Phone Number Work Phone Number: Cell Phone Number: Relationship: Page 5 of 7
Personal Reference Request (Family members or individuals who share the applicant s household may not serve as references.) Applicant s Name: Date: PLEASE PRINT The person named above has applied to Novant Health Prince William Medical Center for a volunteer position. This program requires individuals who are dependable, punctual, motivated, personable, and cooperative. Personal neatness and the ability to accept and follow instructions are also needed. The individual must understand and honor the hospital s policy and patient privacy and must respect and keep confidential all information concerning patients and the hospital. Thank you for your prompt attention to this and please return to the Volunteer Services Office within a week. Instructions: Please evaluate the candidate on each of the following: Characteristic Excel. Good Fair Poor Dependability Punctuality Trustworthiness, honesty, integrity Initiative Respect for others Ability to work as a team player General appearance Ability to problem-solve Flexibility Oral communication skills Written communication skills If you wish to comment further, please do so, on the bottom or back of this form. How long have you known the applicant? In what capacity? May we call you? Best time(s) to reach you. Home phone: ( ) Work phone: ( ) Ext. E-mail address: Cell ( ) Printed name: Signature: FAX to: 703.369.8728 OR Mail to: Novant Health Prince William Medical Center Volunteer Services, Teen coordinator 8700 Sudley Road Manassas, VA 20110 Comments: Page 6 of 7
Personal Reference Request (Family members or individuals who share the applicant s household may not serve as references.) Applicant s Name: Date: PLEASE PRINT The person named above has applied to Novant Health Prince William Medical Center for a volunteer position. This program requires individuals who are dependable, punctual, motivated, personable, and cooperative. Personal neatness and the ability to accept and follow instructions are also needed. The individual must understand and honor the hospital s policy and patient privacy and must respect and keep confidential all information concerning patients and the hospital. Thank you for your prompt attention to this and please return to the Volunteer Services Office within a week. Instructions: Please evaluate the candidate on each of the following: Characteristic Excel. Good Fair Poor Dependability Punctuality Trustworthiness, honesty, integrity Initiative Respect for others Ability to work as a team player General appearance Ability to problem-solve Flexibility Oral communication skills Written communication skills If you wish to comment further, please do so, on the bottom or back of this form. How long have you known the applicant? In what capacity? May we call you? Best time(s) to reach you. Home phone: ( ) Work phone: ( ) Ext. E-mail address: Cell ( ) Printed name: Signature: FAX to: 703.369.8728 OR Mail to: Novant Health Prince William Medical Center Volunteer Services, Teen coordinator 8700 Sudley Road Manassas, VA 20110 Comments: Page 7 of 7