TEEN VOLUNTEER APPLICATION
Qualified teen volunteer applicants are considered without regard to race, color, religion, sex, national origin, marital status, or the presence of non-job related medical condition or disability and must be 15 years or older.
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First Name Middle Initial Last Name E-mail
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Street City Zip Code Home Phone Cell phone
In Case of Emergency, notify______
Phone # ______Relationship ______
Education:
Name of School Town
______
Work Experience:
EmployerPosition When?
______
______
Previous Volunteer Experience:
Agency NameCity/StateType of Service When?
______
______
Reference
Name of individual notrelated to you who will complete the reference form. (Teacher, guidance counselor, etc.)
Name of Reference: ______Relationship: ______
How did you learn about the volunteer opportunities at The Hospital of Central Connecticut?
______
List special skills or interests as they apply to the volunteer position, including other languages spoken:
______
Availability and Assignment Request
Please list days and times you are available to volunteer:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Times Available: ______
Schedule Preference (Include day of week and time period):
First Choice: ______From: ______To: ______
Second Choice: ______From: ______To: ______
Assignment Request: ______
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Authorization for Participation by Parent (for Junior Volunteers ages 15 and over)
I, ______grant permission for
Name Relationship
______to participate in the Junior Volunteer Program at The Hospital of Central Connecticut.
______
Signature of parent or legal guardianDate
Please read carefully:
Applicant’s Statement
I authorize the Volunteer Office to contact the reference provided by me to obtain the information pertinent to my responsibilities as a volunteer at The Hospital of Central Connecticut.
I agree to abide by the policies and regulations of The Hospital of Central Connecticut and the Volunteer Services Departmentand to participate in orientation and training required by the hospital.
I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.
I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the Manager of Volunteer Services to the best interests of the hospital.
I certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that if I am accepted into the Volunteer Services program, false statements may result in my dismissal.
I understand that I am expected to inform the Department of Volunteer Services of any significant change in my health status that would negatively impact on my ability to perform the tasks to which I am assigned.
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Signature of Applicant Date