Teen Volunteer Application

Teen Volunteer Application
Application date
I am 15 years or older
Personal
First name
Middle Initial
Family/last name
DOB
Street Address
Apt/Suite
City
State
Zip/postal
Phone (Home)
Phone (Cell)
E-mail
In case of emergency, notify
Phone
Relationship
Education
Name of school
Town of School
Current Year
Work Experience
Employer
Position/title
Start Date?
Previous Volunteer Experience
Volunteer Organization
Location
Volunteer Position
Start Date?
End date?
References
Name of individual NOT related to you who will fill out reference form (Teacher, guidance counselor, etc.)
1.
Relationship
Do either of your parents work for Hartford Healthcare?
How did you hear about our program?
Please list any special skills or talents that you may have (languages spoken, musical instrument played, singing etc.)
What do you want to get out of your time as a volunteer?
Check here if you are required to do community service for school
If yes, how many hours do you need to complete?
Volunteer Agreement
I agree to abide by the policies and regulations of Hartford Healthcare and the Volunteer Services Department and 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 to the best interests of the hospital by the Manager of Volunteer Services.
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 my ability to perform the tasks to which I am assigned.
Agree
I understand that when flu season begins, the influenza vaccination (flu shot) will be required for all volunteers