January 2013 Dear Applicant, Northside Hospital-Forsyth will be offering a Volunteen Program this summer for teen volunteers between the ages of 15 (must be 15 by January 1, 2013) and 18. This will be an exciting eight week program beginning June 2, 2013 and ending on July 27, 2013. The number of teens we can accommodate is limited. Our objectives of our Volunteen program are to conduct an excellent educational program, to develop an interest in volunteer services for our participants and to provide an opportunity for students to experience the total healthcare environment. The teens accepted for membership in the Volunteen Program will be trained and supervised by either a Northside Hospital-Forsyth Auxiliary member or a hospital staff member. Read the following program requirements before filling out an application: The mandatory orientation is Wednesday, May 29, 2013. This is the only orientation date. Submit an application only if you: o can attend the entire mandatory orientation on May 29 th, o can commit to volunteering at least seven of the eight weeks, and o can attend your first volunteer assignment the week of June 2 nd. The application packet includes: The application page 1 Medical history page 2 Immunization Information Form page 3 Agreement form page 4 Absence schedule form page 5 Forms for two letters of recommendations pages 6 and 7 (Required from teachers counselor, clergy or employer, NOT RELATIVES and must be included in the application packet.) The completed packet must be returned in a sealed envelope to Dianne Baker by Thursday, February 28, 2013. Only completed packets will be considered for acceptance in the program. Please mail your completed application packet to: Dianne Baker, Volunteen Coordinator Northside Hospital-Forsyth 1200 Northside Hospital Drive Cumming, GA 30041 Dianne Baker Volunteen Coordinator 770-844-3390 Dianne.baker@northside.com
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5. _______ Mail your completed packet to: Dianne Baker, Volunteen Coordinator Northside Hospital Forsyth 1200 Northside Hospital Drive Cumming, GA 30041 6. ________ DEADLINE DATE: Thursday, February 28, 2013 by 4 p.m. THERE WILL BE NO EXCEPTIONS TO THIS DEADLINE DATE.
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PLEASE LIST YOUR FAMILY PHYSICIAN AND HIS/HER MAILING ADDRESS Physicians name________________________________________________Phone__________ Address_______________________________________________________________________
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Home Address___________________________________________________________________ Phone_________________ School_____________________________ In Case of Emergency, please notify: ______________________________________________________________________________ Phone________________________________Relationship_______________________________ The Administration at Northside Hospital-Forsyth needs written consent for Volunteers to receive emergency treatment in the event of a serious illness or accident and you cannot be contacted. PARENT/LEGAL GUARDIANS APPROVAL_________________________________________ RELATIONSHIP__________________________________ DATE__________________ MEDICAL HISTORY 1. List all drugs and medications the applicant is presently taking. Drug Dosage ______________________________ ______________________________ ______________________________ 2. 3. ______________________________ Birth date: ________________ Age: ________
List any allergies:____________________________________________________ List any serious injuries, illnesses, surgeries or disabilities ___________________ __________________________________________________________________
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WE MUST HAVE THIS DOCUMENTATION TO PROCESS YOUR APPLICATION As part of the application process in our Volunteen Program, proof of the teen applicant having two (2) doses of measles, mumps, and rubella (MMR) vaccines since his or her first birthday is required. These records can be obtained from the pediatrician or school immunization records. Staple a copy of your official immunization record to this form.
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BECAUSE CONTINUITY IS SO IMPORTANT TO OUR PROGRAM, PLEASE DO NOT APPLY TO OUR SUMMER PROGRAM IF YOU PLAN TO MISS MORE THAN ONE SHIFT DURING THE EIGHT WEEK PROGRAM OR CANNOT ATTEND THE FIRST WEEK OF THE PROGRAM. 1. I will be available the first week of the summer program? 2. Do you have any absences planned during our summer program? If yes, please complete the third question. YES YES NO NO
PLEASE SIGN THIS FORM EVEN IF YOU DO NOT PLAN TO HAVE ANY ABSENCES DURING OUR SUMMER PROGRAM. APPLICANTS SIGNATURE ______________________________________ PARENT/GUARDIANS SIGNATURE ______________________________________ DATE: _________________ DATE _________________
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Dear Ms Baker: _________________________________ has applied for membership in the 2013 Volunteen Program at Northside Hospital Forsyth. I would like to make the following comments on this students Maturity___________________________________________________________ Behavior__________________________________________________________ Dependability______________________________________________________ Ability to follow directions____________________________________________ Additional comments_______________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
I recommend that __________________________________ (be/not be) considered for the Volunteen Program at Northside Hospital Forsyth. ________________________________________________ Signature of person submitting the recommendation _______________________________________________ Title of person submitting the recommendation ______________________________________________ Telephone number Please place this form in a sealed envelope and sign across the seal of the envelope before you return this form to the applicant.
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_________________________________________________________________ _________________________________________________________________ I recommend that __________________________________ (be/not be) considered for the Volunteen Program at Northside Hospital Forsyth. ________________________________________ Signature of person submitting the recommendation ________________________________________ Title of person submitting the recommendation ________________________________________ Telephone number Please place this form in a sealed envelope and sign across the seal of the envelope before you return this form to the applicant.
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