Thank you for inquiring about Driscoll Children's Hospital's Summer Volunteen... We hope that by participating in a selection process very...

Thank you for inquiring about Driscoll Children's Hospital's Summer Volunteen... We hope that by participating in a selection process very...

Thank you for inquiring about Driscoll Children's Hospital's Summer Volunteen program!
We hope that by participating in a selection process very much like the real world hiring practices you will soon face, you will
be better prepared for college and beyond. We ask that you take the same care and attention in filling out this application and
interviewing as you would for a potential employer. To that end we also ask that the parents do not fill out the application or
help write the essay.
Requirements:
1. Nine week commitment with no more than 1 week planned absence (vacation, camp, etc.).
2. Be willing and able to serve a minimum of one four-hour shift per week.
3. Teen must be 14 by January 1st of the year they want to begin volunteering.
4. Turn in the complete application between January 1st and April 15th. Incomplete applications will be rejected.
5. Be willing to submit to a TB test, provided by the hospital (or acceptable alternative, if you react positively)
6. Supply a copy of your immunization records. This is part of the complete application.
7. Teens having participated in previous summers must reapply.
If you simply need service hours for school, church, Scouts, etc., please do not fill out this application. Call 6945011 and ask about Service Project Hours.
The application process:
1. Fill out the attached Summer Volunteen application carefully and completely in blue or black ink.
2. Contact three adults who are not related to you to be references on your application. Let them know you are applying
to be a Volunteen at Driscoll Children’s Hospital and ask them if they would complete one of the reference forms
included in this application packet. Collect the completed references and turn them in as part of the complete
application.
3. Write your essay on the page provided. Typed essays or essays written on notebook paper will not be accepted.
4. Read and sign the Volunteen Code of Conduct, the Summer Volunteen Service Guidelines, the Emergency Medical
Information Sheet and the Photo Consent Form.
5. Have a parent or guardian also sign the Parental Signature Page, the Volunteen Code of Conduct and Photo
Consent Form.
6. Get a copy of your immunization records from your family doctor and include it in your application. Applications
without this will be considered incomplete and rejected.
7. Return your completed application, including all three of your references, essay, Volunteen Code of Conduct, Service
Guidelines, Emergency Medical Information Sheet, Photo Consent Form and a copy of your immunization records to
th
the address below or fax them to (361) 808-2096 before April 15 . Any applications received after this date will be
rejected.
8. Once we receive your complete application, we will contact you to set up an interview. Your application and interview
are then scored to determine which teens will be chosen for the program.
9. If you are accepted into the program, we will call or write and schedule you for orientation.
10. At orientation, Volunteens will learn about volunteering at Driscoll, sign a Training Acknowledgement form, pay their
annual Auxiliary dues ($5), pick up their T-shirts and badges, have their TB tests administered and be placed for
volunteering.
11. Two days later they will return to have their TB tests read.
On behalf of Driscoll Children's Hospital and the Volunteer Services Department, thank you for your interest in volunteering.
If you have any questions about the enclosed application or the Summer Volunteen program, please call (361) 694-5011.
Sincerely,
Volunteer Services Department
Driscoll Children’s Hospital
3533 S. Alameda
Corpus Christi, TX 78411
1
3533 South Alameda
Corpus Christi, Texas 78411
Office: (361) 694-5011
Fax:
(361) 808-2096
OFFICE USE ONLY
Copy Immun. Rec. ________
Application Received ________
Code of Conduct ________
Reference 1 ________
Service Guidelines ________
Reference 2 ________
Emergency Form ________
Reference 3 ________
Photo Consent Form ________
2014 Summer Volunteen Application
Last Name:
First Name:
MI:
Phone numbers. Please list up to three and indicate type (home, applicant’s cell, mom work, etc).
E-mail Address Teen:
E-mail Address Parent/Guardian:
Current Address:
Street
City, State Zip
Date of Birth:
Permanent or Mailing Address (if different from current)
Street
City, State Zip
Driver’s License and State if applicable:
Please circle your t-shirt size (adult sizes): Small/Medium/Large/Extra Large/XX Large
Middle or High School Name:
Grade:
Graduation Year:
Employment History, if any.
Current or Last Employer:
Position:
Duties:
Previous Employer:
Position:
Duties:
Do you have any relatives currently employed at Driscoll Children’s Hospital?
If yes, Name:
Relationship:
Volunteer and Community Activities
Agency/Organization:
Position:
Extension:
Dates:
Please list any special skills or interests:
Additional Languages:
Please list any friends or relatives who volunteer at Driscoll Children’s Hospital:
I verify that the information provided is accurate to the best of my knowledge. I authorize DCH and its agents to confirm all
information provided on the application. I release DCH and all persons and companies from any claims, liabilities or
damages from obtaining or furnishing information about me.
Applicant Signature:
Date:
2
Parent/Guardian Signature Page
This sheet must accompany all applications for applicants under the age of 18.
If selected for the Summer Volunteen program at Driscoll Children’s Hospital, I hereby grant permission for my teen to have an
annual TB test (which may or may not include a chest x-ray) provided at no charge by the hospital.
Parent Guardian Signature:
Date:
The information in the Volunteer application supplied by my teenager is correct. I hereby grant permission for my teen to participate
in the Volunteen program at Driscoll Children’s Hospital and all Volunteen activities on campus. I understand that my teen’s services
are donated to the hospital without contemplation of compensation or future employment, and that those services are given for
humanitarian or charitable reasons. If selected for the Volunteen program at Driscoll Children’s Hospital, I release Driscoll Children’s
Hospital and its employees and adult volunteers from any claims of liability for any damages, injury, or illness resulting to said minor
not occasioned by any fault or neglect on the part of Driscoll Children’s Hospital, while participating in Volunteen activities.
Parent/Guardian Signature:
Date:
I also understand that should my teen need printed verification of his/her summer hours for school or any school activities such as
NHS, JROTC, etc, a letter will be written by the Volunteer Services Coordinator/Director only after a minimum of 32 volunteer hours
have been completed at/for Driscoll Children’s Hospital.
Parent/Guardian Signature:
Date:
3
Essay
Describe in 150 words or less why you want to be a Summer Volunteen at Driscoll
Children’s Hospital. The essay must be handwritten in ink here. (Use front and
back if necessary.)
4
Volunteen Reference Sheet
References cannot be members of your family, or individuals with whom you reside, and must be 18 years or older.
Reference 1
Name:
Street Address:
City, State, Zip
Daytime Phone:
Evening Phone:
Relationship to Applicant:
_________________________ is submitting a Volunteen application at Driscoll Children's Hospital. Three references are
mandatory. Please fill out form and return to the applicant as soon as possible. The information that you provide will allow
us to make an informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
How long have you known the Applicant? ______________________________
Category
Promptness
Emotional Maturity
Verbal Communication Skills
Demeanor/disposition
Ability to work in a team
Ability to work independently
Ability to accept correction/criticism
Ability to follow directions
Ability to work with people of all ages
Level of commitment
Level of responsibility
Ability to manage stress
Quality of work
Not
Observed
Excellent
Very
Good
Average
Fair
Poor
Additional Comments: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature: __________________________________ Date:______________
Print Name: _________________________________
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Volunteen Reference Sheet
References cannot be members of your family, or individuals with whom you reside, and must be 18 years or older.
Reference 2
Name:
Street Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
Relationship to Applicant:
_________________________ is submitting a Volunteen application at Driscoll Children's Hospital. Three references are
mandatory. Please fill out form and return to the applicant as soon as possible. The information that you provide will allow
us to make an informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
How long have you known the Applicant? ______________________________
Category
Promptness
Emotional Maturity
Verbal Communication Skills
Demeanor/disposition
Ability to work in a team
Ability to work independently
Ability to accept correction/criticism
Ability to follow directions
Ability to work with people of all ages
Level of commitment
Level of responsibility
Ability to manage stress
Quality of work
Not
Observed
Excellent
Very
Good
Average
Fair
Poor
Additional Comments: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature: __________________________________ Date:______________
Print Name: _________________________________
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Volunteen Reference Sheet
References cannot be members of your family, or individuals with whom you reside, and must be 18 years or older.
Reference 3
Name:
Street Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
Relationship to Applicant:
_________________________ is submitting a Volunteen application at Driscoll Children's Hospital. Three references are
mandatory. Please fill out form and return to the applicant as soon as possible. The information that you provide will allow
us to make an informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
How long have you known the Applicant? ______________________________
Category
Promptness
Emotional Maturity
Verbal Communication Skills
Demeanor/disposition
Ability to work in a team
Ability to work independently
Ability to accept correction/criticism
Ability to follow directions
Ability to work with people of all ages
Level of commitment
Level of responsibility
Ability to manage stress
Quality of work
Not
Observed
Excellent
Very
Good
Average
Fair
Poor
Additional Comments: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature: __________________________________ Date:______________
Print Name: _________________________________
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VOLUNTEEN CODE OF CONDUCT
As a Volunteen at Driscoll Children’s Hospital:
1. I will keep absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors,
or any other staff. I will not seek to obtain any confidential information from a patient. I understand that a violation of
confidentiality will result in immediate dismissal.
2. I will conduct myself with dignity, courtesy, and consideration of others and endeavor to make my work professional in
quality. I will make every effort to practice the best standards of customer service exhibiting a positive, upbeat, and
caring attitude to help promote a healing atmosphere for patients, families, and the Driscoll team.
3. l will submit to a skin test or chest x-ray, and bring copies of my immunization records as required for my Volunteen
service. I hereby authorize my doctor(s) to furnish the Hospital with information concerning my health.
4. I understand that, as a Volunteen, I will join the Auxiliary to Driscoll Children’s Hospital and am required to pay annual
dues of $5.00. I also understand that the Auxiliary dues are non-refundable.
5. A hospital-issued ID badge (worn visibly over shirt) and t-shirt will be worn with full-length khaki pants and closed-toe,
rubber-soled shoes at all times while volunteering in the hospital
6. I will make my best effort to fulfill my commitment to the Hospital by completing all assignments. If I am released by
my department prior to the end of my shift, I will report to the Volunteer Services offices to obtain further assignment
or release to go home. I also agree to sign in and out upon arrival for and completion of my shifts.
7. I will attempt to resolve any problems related to my Volunteen activities with the Volunteen Coordinator, and, if
unsuccessful, attempt to resolve any such problems with the Director of Volunteer Services.
8. I will not leave the Hospital at any time during my designated shift unless given prior permission/consent from the
Volunteer Services Office. I also understand that if I choose to leave the Hospital at any time without prior
permission/consent, I may be subject to disciplinary action, up to and including immediate termination from the
Volunteen Program.
9. I understand that the Volunteer Service Department reserves the right to terminate my Volunteen status as a result of:
(a) failure to comply with Hospital policies, rules and regulations; (b) absences without prior notification; (c)
unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the Department
Director, would make my continued services as a volunteer contrary to the best interest of the Hospital.
10. I understand that there will be absolutely no loitering or lounging at the Information Desk, Cafeteria, Gift Shops,
Auditorium, McDonald’s, playgrounds, break rooms, restrooms, stairwells, etc. I may wait for my ride in the Volunteer
lounge or the front lobby.
11. Maintain my evening/weekend schedule if a current year-round volunteer.
Applicant Signature and Date
Parent/Guardian Signature and Date
8
Volunteer Service Guidelines
Driscoll Children’s Hospital
Name:
Volunteer Title:
Date:
Department/Location:
Responsible To:
Summer Volunteen
Summer 2012, revised
Various
Service Area Supervisors and Volunteer Coordinators
VOLUNTEEN SUMMARY: The Summer Volunteens will assist hospital staff with the completion of
projects as identified by department supervisors and the Volunteen Coordinator.
VOLUNTEEN TASKS:
• Follow instructions of department supervisor and/or Volunteer Services staff.
• Perform manual tasks such as sorting, envelope stuffing, and packaging of items weighing less
than 10 pounds.
• Run errands within the hospital as directed.
• Answer telephone in courteous and professional manner. Take messages and relay information to
appropriate personnel.
• Give directions or escort patients, their families, and visitors as necessary.
• Retrieve and file patient charts, adhering to HIPAA guidelines. Learn filing systems as needed.
• Look up patient information in computer system as needed.
• Use office equipment (including, but not limited to, computers, copy machine, paper cutter,
laminating machine, fax machine, etc.).
VOLUNTEER CHARACTERISTICS
• Friendly, mature, courteous, positive, motivated and service-oriented.
• Compassionate, kind and sensitive to families facing illness.
• Ability to handle stressful situations and react appropriately.
• Flexibility to adapt to changing service tasks and supervisors.
• Possess good listening and communication skills.
• Ability to handle money, make change, and maintain inventory records.
• Ability to learn and operate computer cash register, where needed.
• Successfully complete training sessions and obtain permits, where needed.
• Identify self as volunteer; wear uniform and badge at all times in hospital.
PATIENT INVOLVEMENT:
• Serve pediatric patients and their families per as required by their departments and DCH policies
on boundaries, confidentiality (HIPAA) and infection control.
VOLUNTEEN DOES NOT:
• Enter any room with an isolation sign.
• Perform treatments, procedures or give out medication, food or beverage to the patient.
• Assist in any physical manner, such as helping a patient get out of bed, walk, etc.
Applicant
Date
Volunteen Coordinator
Date
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Today’s Date:________________
ANNUAL EMERGENCY MEDICAL INFORMATION SHEET
Volunteer Name
(Please print) ____________________________________________ Date of Birth______________
Limitations due to health___________________________________________________________
Medical History__________________________________________________________________
________________________________________________________________________________
Medications and Dosage you take routinely___________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are you allergic to any drugs__________ If so, what____________________________________
Name of Physician_______________________________________ Phone___________________
In Case of Emergency
Contact #1____________________________________________Relationship________________
Home Phone ____________________Cell ___________________ Work_____________________
Contact #2___________________________________________ Relationship_________________
Home Phone ____________________Cell ___________________ Work_____________________
Contact #3____________________________________________ Relationship________________
Home Phone ____________________Cell __________________ Work______________________
In case of an emergency, is there anything else a physician needs to know? _______________
________________________________________________________________________________
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