Duke University Hospital New Junior Volunteer Application Contact Information Name Date (Print clearly) Date of birth Address Street City State Zip Code Telephone Birthday School Grade xx/xx/xxxx Gender Shirt size Email (Print clearly) ******************************************************************************************* Emergency Contact Person Name Relationship to volunteer Telephone Home Work Mobile ******************************************************************************************* Previous Experiences As a Volunteer Other Hobbies, Special Interests Availability Please note: Each student is required to commit to at least 12 hours per week. Students may not volunteer more than 32 hours per week. Please allow some flexibility. We are often short of volunteer commitment of volunteers on Mondays and Fridays. The more flexible you are, the more opportunities you will have. Circle all days and shifts you are available below. Only circle the times and days that you are actually able to volunteer. How many hours do you want to work each week between 12 32 hours? Monday Mornings Afternoons Tuesday Mornings Afternoons Wednesday Mornings Afternoons Thursday Mornings Afternoons Friday Mornings Afternoons Saturday Mornings Afternoons Sunday Mornings Afternoons
List your preferred days if applicable, i.e as it pertains to transportation, etc. If accepted to the program, every effort will be made to accommodate your request; however, this is not always possible. Why do you want to be a volunteer? (Use the back of this sheet if you need more space) In joining the Duke University Hospital volunteer program, I agree to take my work seriously and take advantage of the opportunities the program offers in the hope that my service will be helpful not only to the hospital, but to the patients and community as well. o I acknowledge that I will commit to serve at least seven weeks of the eight-week program, or as approved by my supervisor. If I am accepted, I will notify the Volunteer Services manager if my summer schedule changes. I realize I may lose my spot if my new schedule does not fit with the program. o o I understand that I should arrive on time and stay on the hospital campus at all times (including lunch). I will ensure that my volunteer supervisor knows where I am at all times. I take responsibility for my actions while serving as a volunteer and will uphold these and all other hospital and departmental policies, as presented in volunteer orientation. I am aware that Duke University Hospital does not provide insurance coverage for volunteers if injured or if damage occurs to the worker s personal property while acting as a volunteer. I further understand that I am not entitled to worker s compensation benefits, health insurance benefits or any other benefit available to employees of Duke University Hospital. I agree that I will not hold Duke University Hospital or its officers or agents liable for any injury sustained to person or property while acting in a volunteer capacity. I understand that if I am accepted into the program there will be a mandatory orientation on Monday, June 11 th from 8am 11:30am that I must complete in order to volunteer the summer of 2018. I understand that there will be no alternative dates for this training. Applicant Signature Date Parent/Guardian Signature Date Application Requirements To be considered for volunteer placement, sign up for interview time online-note your interview time. Your interviewer is holding that time for you. Please complete the following: Please bring all completed forms to interview in order to be considered for placement. o Junior volunteer application o Health screen form completed by physician o Two reference forms (to be completed by non-family members) o School counselor form o Vacation form
DUKE UNIVERSITY HOSPITAL JUNIOR VOLUNTEER STUDENT COUNSELOR FORM For Junior volunteer: Please have your counselor and parent complete this form. Please do not mail this form. If you have questions, please call the Volunteer Services Office at (919) 681-6088. For Parent: As Parent/Guardian I hereby give my permission for the release of this requested information. Parent/Guardian Signature: Date THIS REPORT IS STRICTLY CONFIDENTIAL Dear Counselor: Please return directly to the student in a sealed envelope with your signature across the back of the envelope before March 9, 2018. The student named below is applying for the Junior Volunteer Program at Duke University Hospital. The following information is required: Student name: (please print) Name of School: (please print): Number of: Tardies Absences Suspensions Grade Point Average: Please comment on whether or not you would recommend this student to serve in the Duke University Hospital Junior Volunteer summer program. Counselor signature Counselor name and telephone number (Please print)
DUKE UNIVERSITY HOSPITAL JUNIOR VOLUNTEER PROGRAM REFERENCE FORM *Must be included with packet and brought by student to interview please do not mail. Dear, Your name has been given as a character reference for who has applied to be a Junior Volunteer at Duke University Hospital. Thank you for your time and assistance. Please complete the following information and return directly to the student in a sealed envelope with your signature across the back of the envelope before March 9, 2018. How do you know this person? How long have you known this person? Which extraordinary skills and/or attributes does this person have that may contribute to his/her service as a volunteer? Please circle a rating on this applicant on a scale of 1-4 with 4 as Excellent on the following attributes. Has a Positive Attitude 1 2 3 4 Honest/Trustworthy 1 2 3 4 Dependable 1 2 3 4 Demonstrates Initiative 1 2 3 4 Ability to follow instructions 1 2 3 4 Ability to treat individuals with patience and compassion 1 2 3 4 Do you know of any reason why this individual should not be accepted as a Junior Volunteer? _ Printed Name and Organization Name E-Mail Address Signature Phone Number
DUKE UNIVERSITY HOSPITAL JUNIOR VOLUNTEER PROGRAM REFERENCE FORM *Must be included with packet and brought by student to interview please do not mail. Dear, Your name has been given as a character reference for who has applied to be a Junior Volunteer at Duke University Hospital. Thank you for your time and assistance. Please complete the following information and return directly to the student in a sealed envelope with your signature across the back of the envelope before March 9, 2018. How do you know this person? How long have you known this person? Which extraordinary skills and/or attributes does this person have that may contribute to his/her service as a volunteer? Please circle a rating on this applicant on a scale of 1-4 with 4 as Excellent on the following attributes. Has a Positive Attitude 1 2 3 4 Honest/Trustworthy 1 2 3 4 Dependable 1 2 3 4 Demonstrates Initiative 1 2 3 4 Ability to follow instructions 1 2 3 4 Ability to treat individuals with patience and compassion 1 2 3 4 Do you know of any reason why this individual should not be accepted as a Junior Volunteer? _ Printed Name and Organization Name E-Mail Address Signature Phone Number
Duke University Hospital Junior Volunteer Physician form To be completed by your physician only Please note: We are unable to consider applicants who do not bring this signed form to their interview. **This is the only health screen form needed. Please do not bring individual immunization records** I, certify that (printed name of physician) (printed full name of student) (complete mailing address of student) Has received the following vaccinations and TB test: Provider initials Date 1) 2 varicella vaccines 2) 2 MMR vaccines 3) Tdap vaccine 4) Polio vaccine 5) Tb test within the last 90 days, with a negative result. *Date of TB test* (date must be completed) All of the above vaccinations and a TB test within the past 90 days are required to volunteer within Duke Health. By my signature below, I certify that this student has received all vaccines listed above and has had a negative TB test within the past 90 days. (Printed name physician) (Signature of physician) (Telephone number of medical practice) (Complete mailing address of medical practice)
Junior Volunteer Vacation form The 2018 Junior Volunteer Program is from June 11 th - August 3, 2018. **Mandatory orientation will be held on Monday, June 11 th from 8am -11:30am ** During the program, each Junior Volunteer is permitted to take one week of vacation. Additional time off can be discussed with supervisor. Regular attendance is a program requirement. If attendance becomes a concern, a Junior Volunteer may be asked not to continue in the program. Please list the dates you will be taking vacation below and turn this sheet in to your coordinator on the first day of your volunteer service. Please do not call, e-mail, or verbally tell your coordinator your vacation dates this form must be presented in writing the first day you volunteer. Please only list the dates that you would normally be scheduled to volunteer (i.e., if you will be away from June 20 25, only list those days you are actually scheduled to volunteer.) Our end of summer pizza party will be held on Wednesday, August 1st More details to be announced. Hope you can plan to be there to celebrate with your fellow junior volunteers! Name of student (please print) E-mail address (please print clearly) Cell phone number June vacation dates July vacation dates August vacation dates Volunteer Program: Coordinator Name: Coordinator e-mail address: Coordinator phone number: Your Volunteer Schedule: