Volunteer Name:

Volunteer Age:

Volunteer Grade:

Junior Volunteer Application

(Ages 14 - 21)

Medical Center Alliance

3101 North Tarrant Parkway

Fort Worth, TX 76177

Phone: 817-639-1000

Fax: 817-639-1727

If you are unable to drop off application at the front desk, you are welcome to fax it to the number above.

JuniorVolunteerGuidelines

ThankyouforyourinterestinbecomingaJuniorVolunteeratMedical Center Alliance.

PleasecarefullyreadtheguidelinesandrulesthatapplytoJuniorVolunteersandhaveaparentorguardianreadthemalso.

I.REQUIREMENTSJr. Volunteer Ages:14–21

Forms: AllApplication FormsandotherrequiredformsmustbecompletedbeforeyouwillbeconsideredforaJuniorVolunteerposition.TheFollowingitemsarerequired:

  • CopyofcurrentReportCard(mustmaintaina"B"averageorhigher)
  • Copyofcurrentup-to-dateimmunizationrecord
  • 2lettersofrecommendationfromsomeoneotherthanafamilyisrequired.

Screening:Everyvolunteerwillhavetopassabackgroundcheck,drugscreenand TBskintestbeforetheycanstart.

Interview:Youwill meetwiththe Volunteer Coordinator or Employee Health NursetodiscusstheVolunteerGuidelines,andrequirementsafteryouhavecompletedallnecessarypaperwork.

Service:Werequireaminimumof4hours per week per semester ofserviceasaJuniorVolunteer.ThisusuallybeginsinJuneandendsinSeptemberofeachyearbutmaybeextendedonanindividualbyindividualcase.

Medical: AnnualPPD(Tuberculosisscreening)forallVolunteersisrequiredwithin30daysofyourstartdate.VolunteersmayhavethesetestsatMedical Center Allianceatnocharge. Parental/Guardian consentforPPDisrequired.MedicalrequirementsmustbecompletedBEFOREservicebegins.

Training: VolunteerOrientationattendanceisrequiredbeforeyoumaystartyourservice.Youwillbeinformed ofthedateandtimeoftheorientationclassafteryouareacceptedtotheprogram.

II.ATTENDANCEANDABSENCES

JuniorVolunteersbecomeanintegralpartoftheirdepartmentandtheHospitalstaff reliesontheirpresenceasscheduled.WeunderstandthatallVolunteersmaygetsick,takevacations orhaveunavoidableconflicts(exams!)ontheirregularvolunteerday.AmessagemaybeleftontheVolunteerCoordinators phoneat817-639-1937or817-688-5858 whenyouarenotabletofulfillyourdutiesforthatday.

VolunteerswhohavetakenanextendedleaveofabsencemustcontacttheVolunteer Coordinatorbeforereturningtoservice. Similarly, pleasenotifytheVolunteerCoordinatorifyouareresigningfromtheVolunteerServiceandreturnyourIDbadge.

III.UNIFORMANDDRESSCODE

EachJuniorVolunteerisrequiredtowearthecorrectapprovedJuniorVolunteeruniformatalltimeswhileonduty.The JuniorVolunteerrequireduniformisthefollowing: MaleandFemaleJuniorVolunteerUniformsarethesame.

  • Shirts-WHITEcollared short or long-sleeve shirt.
  • Pants-Khakidressslacks.Nohiphugger,lowrider,orbaggypantsallowed.
  • Donotuseperfumeorotherscentedproductsasitmaycauseallergicreactionsinsomepatients atanytimewhileonduty.

IV.VOLUNTEER ASSIGNMENTANDSCHEDULES

EveryJuniorVolunteerisrequiredtocommit toanassignmentofone4hour shiftper weekforaminimumofone semestercommitmentperiod.WeekendshiftsareavailableIFAPPROVED by Volunteer Coordinator.

YouwillbegivenoneormoreregularvolunteerassignmentsbasedupontheneedsoftheHospital. Everyeffortwillbemadetotakeintoaccountyourspecialinterestsandskills.

Available shifts asfollows:

  • 8:00a.m.–12:00p.m.Monday-Friday
  • 1:00 a.m. –5:00 p.m. Monday-Friday

Jr.Volunteer’sdutiesincludebutarenotlimitedto:

  • Escort families,visitorstovariousareasasneeded.
  • MakeHappy Cart roundsonallfloorsseveraltimesduringyourshift.
  • Transportspecimens,supplies,etc.tolabandotherdepartments.
  • Runerrandsasrequestedbyunitstaff
  • Assistpatientwithmeals - open containers,setup trays,etc.
  • Helptransportdischargedpatientsoffunit.
  • Keeppublicareastidy,uncluttered,readingmaterialsprovided.
  • Anyotherdutiesasassignedby Director or Supervisor.

WeexpectourJuniorVolunteerstocontinuetheirtraditionofmatureandresponsiblebehavioratalltimes.ThisincludesawillingnesstoacceptsupervisionandtofollowHospitalrules.

V.SIGN-INPROCEDURE

Whenyouarriveforyourshift,signinatthefront desklocatedonthe1stfloor. Contact the nursing supervisor at *91888 and have them sign you in/out. Youareresponsible forkeepingtrackofthehoursyouwork.PleasedonotbringvaluablesorcashtotheHospitalexceptforwhat youabsolutelyneed.

VI.MEALBREAKS

YourVolunteerPhotoIDentitlesyouto onefreemealinthecafeteriawhileonduty.DonotuseyourVolunteerPhotoIDtopurchaseitemsfromthecafeteriaforanyoneotherthanyourself.

VII.PARKING

Volunteersarenot allowed to park in patient/visitor parking directly in front of Medical Center Alliance.

I, onthisday,havereadtheguidelinestotheVolunteerProgram. Iherebyagreetoallthetermsandconditionstothisprogram.

Signature of Jr. Volunteer______

Astheparent/legalguardianofthisjuniorvolunteer,Ihavereviewedtheserequirementsandgivepermissionforthemtoparticipate.

Name: ______

Signature: ______Date: ______

Inordertoapplyforthisvolunteeropportunity,youmustreadandagreetothetermsaswellascompleteandreturntheattachedformstoMedical Center Alliance front desk.

Forquestionsontheprocess,pleasecontactAlex Roberson,

JR.VOLUNTEERAPPLICATION

Pleaseprintclearlyandanswerallquestions,which applytoyou:

LastNameFirstNameMiddleName

HomeAddressCityStateZipCode

HomePhoneCellPhone

Email Address: ______

Do you work? Y or N If yes, where do you work? Maywecallyouatwork?Duringwhatdaysandhours? StudentGradeLevel ______

What school do you attend? ______

DaysAvailable: Monday / Tuesday / Wednesday / Thursday / Friday
TimeAvailable:Morning or / Afternoon

VolunteerCategory:Junior(14to21yearsofage)

VolunteerExperience

Pleaselistanyvolunteerexperience,includingschoolandchurchvolunteeractivities:Agency City.State Dates Duties

Training,Education,Certification

Pleaselistanyspecialtraining,licenses,certificationsordegrees:

Specialinterests

Pleaselistyourhobbies,skillsorareasofspecialinterest:

References

Pleaselisttwoadultpersonalreferences,otherthanrelatives,whomyouhaveknownforatleasttwoyears:

NameAddressPhoneRelationshipYearsKnown

CONFIDENTIALMEDICALDISCLOSURE

Thisformisnot tobekeptinthevolunteerfile.ItistobeforwardedtoEmployeeHealthNurseimmediatelyuponcompletion.

Name: ______Date: ______

Address: ______

Contact Number: ______

Emergency Contact(s)

Name: ______Relationship to you: ______

Address: ______

Phone Number: ______

Name: ______Relationship to you: ______

Address: ______

Phone Number: ______

Please list any medical conditions you have:

______

______

I certify that the above information is true and complete to the best of my knowledge at the time of application to become a volunteer at Medical Center Alliance. I understand that it is my responsibility to update this information with the Employee Health Nurse or Volunteer Coordinator if any changes occur. I hereby give Medical Center Alliance permission to release pertinent information in the event of a medical emergency.

Signature: ______Date: ______