SKY LAKES MEDICAL CENTER
JUNIOR VOLUNTEER APPLICATION
PLEASE PRINT CLEARLY
NAME
AGE
Last name
Home PHONE
ADDRESS
first name
BIRTHDATE
middle initial
Cell PHONE
CITY
STATE
CURRENT
GRADE
SCHOOL
ZIP
GRADUATION
YEAR
REFERENCES: Written references from three adults, NOT RELATIVES, who know you well. One reference must be
from a teacher who has had you in class during the past year. Please list the names and relationships of those you
have asked to complete a reference form.
Name
Relationship
1.
2.
3.
Have you ever been convicted of a crime? (It is necessary to answer this question honestly, as a background
check will be conducted on all applicants before being placed as a volunteer.)
Yes
No
If “Yes”, Please explain. (Conviction is not an automatic bar to placement. Each case will be considered on an
individual basis.)
Have you ever used a different name? (Legally changed, etc.)
Yes
No
If “Yes”, what was the name?
IN CASE OF ILLNESS WHILE ON DUTY, THE PERSON WE SHOULD CONTACT?
name
relationship
address
home phone
cell phone
work phone
ACTIVITIES you are involved in
Continued on reverse side
I WANT TO BE A JUNIOR VOLUNTEER BECAUSE
If I am accepted into the Sky Lakes Medical Center Junior Volunteer Program I will be dependable,
responsible, confidential, neat and clean, punctual and courteous while in the Junior Volunteer Program. I
understand I will be required to have a TB Test that will be provided by The Medical Center.
I declare that all the foregoing statements are true and correct to the best of my knowledge. I also authorized
The Medical Center to conduct a background check and to contact my references to make inquiries to
determine my suitability for service and training. I hereby release them and The Medical Center from all
liability for issuing or receiving same. All facts stated in the application are open to investigation and if
anything contained herein is found to be false and misleading, I understand that I will be subject to dismissal
at any time without notice. I agree that if accepted into the Junior Volunteer Program, I will abide by all
policies and procedures established by The Medical Center.
signature of Junior Volunteer Applicant
date signed
FOR PARENT or GUARDIAN:
has my permission to participate in
the Junior Volunteer Program at Sky Lakes Medical Center. I understand that he/she will be required to have
a TB Test that will be provided by Sky Lakes Medical Center. I understand a parent or guardian MUST
attend the Volunteer Orientation with my teenager.
printed name of parent or guardian
signature of parent or guardian
date signed
* * * * * * * * * * * * * * * * * * * * * * * * * OFFICE USE ONLY BELOW THIS LINE * * * * * * * * * * * * * * * * * * * * * *
Volunteer Orientation
Joining Fee
Interviewed
Confidentiality Agreement
st
1 TB Test Completed
Photo ID Badge issued
reviewed 02/04; 11/06; 04/07; 05/07; 06/07; 09/08; 10/10; 12/12
Volunteer Services
MAH
HIPAA Agreement
nd
2 TB Test Completed
Uniform