JUNIOR VOLUNTEER APPLICATION
To be filled out by Volunteer Manager:
Status: Junior
Start Date: ____/_____/_______ Badge # _________
Group: _____________________________________
Today’s Date:_____/______/________
Name_____________________________________________________________________________________
Last
First
Middle
Address __________________________________________________________________________________
Street
City
State
Zip
Date of Birth: _____/______/_______
Home Phone # _____-_____-_______ Work Phone # ______-_____-_______ Cell # _____-______-_______
Social Security Number: ______-______-________Guardian’s Name_____________________________
Address_________________________________________________Guardian’s Telephone_______________
School currently attending _____________________________________________________Grade ________
Type of Volunteer Work Desired _____________________________________________________________
__________________________________________________________________________________________
In case of Emergency, please notify: Name _____________________________________________________
Relationship ______________________ Phone #: Home _____-_____-_____Work/Cell _____-_____-_______
Circle the days of the week that you can serve at Pocono Medical Center:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning ______ Afternoon ______ Evening ______ From ________ A.M. to _______ P.M.
Will you be available throughout the entire year? YES / NO
If NO, please list the months that you would be unavailable _________________________________________
_________________________________________________
Applicant’s Signature
Thank you for your interest in our Volunteer Program.
Consent to Volunteer:
If accepted, I __________________________ agree to cooperate with him/her in complying
(parent or guardian)
with rules and regulations which include providing transportation and seeing that he/she
faithfully maintains his/her scheduled duty time.
I further concur that while on duty he/she is to remain on the Medical Center’s property unless
otherwise instructed by me.
_______________________________________________
Signature of Parent or Legal Guardian
_____________________________
Date
Qualified applicants are considered for all positions without regard to race, color, religion, sex,
national origin, age, disability, or status.
My signature below authorizes the release of reference information and affirms all the facts set
forth in my application for volunteering are true and complete.
A volunteer’s service is by mutual consent and may be separated by the Volunteer Services
Manager or the volunteer, at any time with or without cause. It is understood that while a
volunteer, all hospital rules, regulations and procedures must be abided by.
It is also understood that failure to carry out the responsibilities of a volunteer and conduct
oneself in the best interest of the Medical Center and its patients, is grounds for immediate
separation.
_____________________________________________
Signature (Volunteer)
______________________________
Date
Dear Parent:
It is the policy of Pocono Health System that TB screening will be done annually as required by local
regulations and as recommended by Centers for Disease Control to promote employee, volunteer and
patient health.
All employees and volunteers will be screened with Mantoux skin test prior to being placed and
annually thereafter. If the Mantoux (Tine is not acceptable) has been done elsewhere within the past
year, please present documentation to the Employee Health Nurse.
Please do not hesitate to contact me if you have any questions.
Very truly yours,
Camille R. Fjeld
Volunteer Manager
========================================================================
I give permission for my child, ________________________________ to have the Mantoux Skin
Name of Child
test for TB. I understand this is a requirement in order to be a Junior Volunteer at PMC.
____________________________________________
Signature of Parent/Guardian
________________________
Date
Street:____________________________________________City:_________________________
State:_____________________ Zip_________ Phone: __________________________________
SCHOOL GUIDANCE COUNSELOR
CONFIDENTIAL EVALUATION
Student’s Name_____________________________________________________________________
School Name ____________________________________________________Grade _____________
CONSENT TO RELEASE SCHOOL RECORDS
I authorize a representative of the above mentioned school to complete the School Guidance
Counselor Evaluation Form in connection with the above student’s application to participate in
the Junior Volunteer Program at Pocono Medical Center. I understand the purpose of the form
is to aid Pocono Medical Center in selecting qualified Junior Volunteers.
All information provided by the school will remain confidential.
_________________________________________________
Signature of Parent or Legal Guardian
________________________
Date
Do not write below this line – To be completed by Guidance Counselor
I would rate this student as follows: (Please circle the appropriate choice.)
1. Requires (less, more, about the same) amount of instructions as most students.
2. Requires (minimal, occasional, considerate) supervision or direction.
3. (Follows through, does not follow through) on assignments.
4. Interacts (well, very well, not well) with peers.
5. Interacts (well, very well, not well) with older persons.
6. (Has, does not have) adequate emotional stability to work with patients.
7. (Is, is not) regular in school attendance. If not, what is the cause of absence or tardiness?
____________________________________________________________________________
I recommend this candidate to be accepted as a Junior Volunteer.
I do not recommend this candidate to be accepted as a Junior Volunteer.
Comments_____________________________________________________________________
______________________________________________________________________________
___________________________________________________________ ___________________
Signature and Title
Date