5126 Hospital Drive
Covington, GA 30014
Tel: 770.788.6553
Andrea.Lane@piedmont.org
Junior Volunteer
Program
Information Packet
Piedmont Newton Hospital
Volunteer Services
Summer 2016
June 13 – July 22
Rev. 1-21-2016
1|Page
January 22, 2016
Dear Prospective Junior Volunteer and Parent or Guardian,
Thank you for your interest in participating in the Piedmont Newton Hospital Volunteer Services 2016 Junior
Volunteer Program. This program runs for 6 weeks from June 13 - July 22, 2016. It is for students from Newton
County and children and grandchildren of Piedmont Newton employees and volunteers. This is not an internship
program but rather a service to Piedmont Newton Hospital. This program provides an opportunity for students to gain
exposure to a hospital environment, while making a contribution to the community.
To participate in this program you must volunteer a minimum of 20 hours by working one, four hour shift per week.
Therefore, please consider carefully whether this time commitment will fit in with any family vacations, sport
commitments, part-time work schedules, or any other obligations you may have. Your willingness and ability to make
a commitment to your volunteer assignment is crucial because the department in which you will be volunteering
depends on you. As such, you will only be permitted one week off in order to satisfactorily complete the program.
Included herein is the Application Packet. Below is important information regarding the application process:
1. The Junior Volunteer Application Packet will be available on February 1, 2016.
2. The following forms must be returned by all applicants by Friday, April 1, 2016:
a. Junior Volunteer Application
b. Two Letters of Reference using the enclosed forms and returned as specified on the forms.
c. Returning Jr. Volunteers are not required to interview, but are required to call the Volunteer Office to
confirm receipt of all application paperwork.
d. Signed “Junior Volunteer Agreement”
e. Signed “Parental/Legal Guardian Agreement”
1. Interviews will be held between 3:00 pm and 5:30 pm on Tuesday, April 19, Wednesday, April 20 and
Thursday, April 21.
2. Uniform polo shirts will be distributed at orientation on Friday, June 10th. A $20 uniform shirt fee will be
collected at that time.
3. Upon acceptance to the program, you will receive information via email regarding the required urine drug
screening, tuberculosis screening, and mandatory orientation scheduled for Friday, June 10 from 8:00 a.m. to noon.
4. Due to the limited number of available positions, final placement will be determined by lottery. The interview
process does not guarantee placement.
5. You will be notified by e-mail only as to whether or not you have been accepted to the program. Your
assignment will be given to you at orientation.
If you have any questions or concerns, please contact the Volunteer Services Office at (770) 788-6553, or by e-mail at
Andrea.Lane@piedmont.org. Our mailing address is: 5126 Hospital Drive, Covington, GA 30014. The Volunteer
Services office is staffed Monday-Friday from 8:00 a.m. – 4:30 p.m.
Sincerely,
Andrea Lane
Manager, Volunteer Services
Rev. 1-21-2016
2|Page
TABLE OF CONTENTS
Application …………………………….………………………………………………………………………4
New Applicant - Reference 1 ……….………………………………………………………………………….6
New Applicant - Reference 2 …………………………………………………………………………………..7
Junior Volunteer Agreement……………………………………………………………………………………8
Parental/Legal Guardian Agreement: ……………………………………………………………..……………9
JuniorVolunteer Dress Code…………………………………………………………………………….…….10
Zero Tolerance Policy…………………………………………………………………………………………11
Rev. 1-21-2016
3|Page
FOR OFFICE USE ONLY
Date Received
_____/____/_____
2016 JUNIOR VOLUNTEER
Application
Check One:
(print) Last Name:
 New Junior Volunteer
 Returning Junior Volunteer
First Name:
Street Address:
Home Phone:
City:
E-mail:

Sex:  M  F
Cell Phone:
Middle Initial:
State:
Zip:
Birthdate:
/
/
School Attending:
Age:
Class of:
Do you have a family member who is an employee or a volunteer at Piedmont Newton Hospital?
 Yes No
- If yes, please list name(s), relationship(s) and work area:

How did you hear about the Jr. Volunteer Program at Piedmont Newton Hospital?

Do you have any physical limitations requiring special accommodations in order for you to volunteer?
 Yes No
-
If yes, please explain:
Interest/Skills

List any prior work experience or volunteer service:

List foreign languages that you write or speak:

List any other special skills such as keyboarding, computer skills, sign language, etc.:
Rev. 1-21-2016
4|Page
Scheduling
Check shift and days you are available for volunteer assignments (Note: exact hours vary by department needs).
Weekday
Mon
Tue
Wed
Thu
Fri
Morning
Afternoon
We realize you may not know all of your summer plans, but please list the dates you will be unable to work this summer
due to family vacations, driver’s education, school, band camp, sports, etc. (To participate in this program, you must
volunteer a minimum of 20 hours by working one, 4-hour shift per week.)
Dates Unavailable:
Parental Information and Agreement
Name of Parent/Legal Guardian
(print)
Street Address:
Home Phone:
City:
State:
Work Phone:
Zip:
Cell:
E-mail:
All Jr. Volunteers must be covered by a family hospitalization policy, which must be listed below. Should it become
necessary to seek medical attention in the emergency room, your insurance will be utilized.
In case of emergency, notify:
Name:
Relationship:
Phone No:
In the event I cannot be reached, permission is hereby granted to treat my child, _______________________________,
for any problem that might occur while on duty as a volunteer.
Parent/Legal Guardian Signature:
Date:
/
/
Insurance Information:
Policy Holder’s Name:
Policy No:
Company:
I hereby certify that the answers on this application are true and correct and that any omission of facts or
misrepresentation, misleading or false information on my part will be grounds for dismissal as a volunteer. I will abide
by all rules and regulations established. I understand that at anytime I fail to abide by the established rules and
regulations, I will forfeit my privilege to serve as a volunteer and may be discharged without warning or notice.
Acceptance as a volunteer is contingent upon satisfactory references and verification of the information submitted. I
authorize that all employers, schools or references thus contacted shall be released from all liability in answering
inquiries related to my application.
/
Jr. Volunteer Signature
Rev. 1-21-2016
/
Date
/
Parent/Legal Guardian Signature
/
Date
5|Page
2016 JUNIOR VOLUNTEER
New Applicant – Reference #1 – School Counselor
Volunteer’s Last Name:
First Name:
Date:
/
/
School Attending:
Reference’s Name
(Printed)
First & Last Name:
Contact Number (optional):
Dear School Counselor,
The individual named above has applied for the JUNIOR VOLUNTEER PROGRAM at Piedmont Newton
Hospital. Your assistance is requested in evaluating the applicant with regard to the following qualities. Candid
completion of this information will give us an opportunity to properly review his/her qualifications and assign them
to an appropriate area if all qualifications are satisfactorily met.
Personal Appearance:
Maturity:
Ability to get along with others:
Attitude toward taking directions:
Sense of Responsibility:
Dependability:
Additional Comments:
Signature:
Date:
To assure confidentiality and proper processing of this information, please complete this form and return to
student in a sealed envelope or you can scan and email it directly to the Andrea Lane at
Andrea.Lane@piedmont.org. If you have any questions, please call the Volunteer Office at (770) 788-6553.
Rev. 1-21-2016
RETURN TO VOLUNTEER SERVICES OFFICE
6|Page
2016 JUNIOR VOLUNTEER PROGRAM
New Applicant – Reference #2 – Personal
Volunteer’s Last Name:
First Name:
Date:
/
/
School Attending:
Reference’s Name
(Printed)
First & Last Name:
Contact Number (optional):
Dear (Please circle one) Principal / Teacher / Coach / Minister or Adult Friend:
The individual named above has applied for the JUNIOR VOLUNTEER PROGRAM at Piedmont Newton
Hospital. Your assistance is requested in evaluating the applicant with regard to the following qualities. Candid
completion of this information will give us an opportunity to properly review his/her qualifications and assign them
to an appropriate area if all qualifications are satisfactorily met.
Personal Appearance:
Maturity:
Ability to get along with others:
Attitude toward taking directions:
Sense of Responsibility:
Dependability:
Additional Comments:
Signature:
Date:
To assure confidentiality and proper processing of this information, please complete this form and return to
student in a sealed envelope or you can scan and email it directly to the Andrea Lane at
Andrea.Lane@piedmont.org. If you have any questions, please call the Volunteer Office at (770) 788-6553.
Rev. 1-21-2016
RETURN TO VOLUNTEER SERVICES OFFICE
7|Page
2016 JUNIOR VOLUNTEER PROGRAM
Junior Volunteer Agreement
As a Jr. Volunteer at Piedmont Newton Hospital, I promise to:
3.
Obtain, complete and submit all required information necessary for processing by Friday, April 1, 2016
to Piedmont Newton Hospital Volunteer Services, 5126 Hospital Drive, Newton, GA 30014.
4.
Interviews will be held between 3:00 pm and 5:30 pm on Tuesday, April 19, Wednesday, April 20
and Thursday, April 21. YOU must call to schedule your interview appointment. We will do our best
to accommodate your appointment time request.
5.
Returning Jr. Volunteers are not required to interview, but are required to call the Volunteer Office to
confirm receipt of all application paperwork.
6.
Obtain Urine Drug Screening and TB (Tuberculosis) Test at Occupational Health Services, free of
charge through Piedmont Newton Hospital, and update my tetanus shot, if necessary.
7.
Attend a one-day mandatory Orientation and Training Meeting for all new and returning Jr. Volunteers
to be held on Friday, June 10, 2016 from 8:00 a.m. to 12:00 p.m. at the hospital.
8.
Serve a minimum of 20 hours from June 13 – July 22, 2016. (All new and returning Jr. Volunteers are
required to serve one, 4-hour shift per week.
9.
Ensure that written, advance notification of time to be missed for family vacations, driver’s education,
school, band camp, sports, etc. is included in the application.
10.
You will be required to find a substitute if you are unable to volunteer on your scheduled date. We will
provide a schedule and sub list at orientation.
11.
Be dependable and fulfill my work assignments. Always conduct myself with dignity and courtesy.
Provide my highest quality work.
12.
Be punctual and sign in and out at the designated location.
13.
Read and comply with the “Zero Tolerance Policy.”
14.
Consider all information I hear, either directly or indirectly, concerning a patient or a member of the
hospital staff to be confidential.
15.
Act and dress professionally, following the Piedmont Healthcare’s Code of Conduct, Policies &
Procedures and Dress Code.
16.
Be committed to enjoying this learning experience by serving patients, visitors, staff and fellow
volunteers in a friendly, courteous manner.
17.
Return my Identification Badge at the end of the 6-week program.
18.
Check my e-mail regularly for messages from the Volunteer Services Office as all information will be
sent electronically.
Junior Volunteer Signature
Date:
/
/
E-Mail
Rev. 1-21-2016
RETURN TO VOLUNTEER SERVICES OFFICE
8|Page
2016 JUNIOR VOLUNTEER PROGRAM
Parental/Legal Guardian Agreement
1. I hereby permit my child, __________________________________________________ to join the Junior
Volunteer Program at Piedmont Newton Hospital. I understand the importance of responsibility and will
assist my child in complying with the program’s rules and regulations. I will assume responsibility for
his/her transportation.
2. I have read and understand the “Zero Tolerance Policy.”
3. I agree that my student’s Identification Badge will be turned in at the end of the 6-week program.
4. In the event of a medical emergency, I permit the physicians in the Emergency Department of Piedmont
Newton Hospital to treat my student.
5. I understand that in order for my student to participate in the program, all necessary information must be
obtained, completed and submitted by Friday, April 1, 2016.
6. Interviews will be held between 3:00 pm and 5:30 pm on Tuesday, April 19, Wednesday, April 20 and
Thursday, April 21. I agree to attend the interview with my student as a mandatory part of the
application process. Please note: THE STUDENT needs to call to schedule their interview appointment.
We will do our best to accommodate their appointment time request.
7. Returning Jr. Volunteers are not required to interview, but are required to call the Volunteer Office to
confirm receipt of all application paperwork.
8. I understand my student will be required to pay $20.00 for the uniform shirt.
(All volunteers will need a new shirt as our colors and logo has changed to Piedmont.)
9. I hereby give permission and will accompany my student to receive a Urine Drug Screening and TB
(Tuberculosis) Test at the Occupational Health Services office located on the 2nd floor of the main hospital
building. Tel: (770) 385-7895. Screenings and tests are provided by Piedmont Newton Hospital at no
charge.
10. I understand that my child is required to serve a minimum of 20 hours from June 13 – July 22, 2016.
Written, advance notification of time to be missed for family vacations, driver’s education, school, band
camp, sports, etc. must be included in Application Form. Last minute schedule changes are very
disruptive to the hospital staff and volunteer office. The Volunteer Office staff is not responsible for
adjusting your child’s schedule so that they can obtain the necessary hours.
11. I understand that all information will be communicated electronically to my student’s e-mail and they will
need to check their email regularly for messages. Please supply your email address if you would like to
receive all emails we send to your student.
Parent/Legal Guardian
Signature:
Date:
/
/
E-mail:
Rev. 1-21-2016
RETURN TO VOLUNTEER SERVICES OFFICE
9|Page
2016 JUNIOR VOLUNTEER PROGRAM
Junior Volunteer Dress Code
1.
Red polo shirt with the hospital logo (to be purchased at the Volunteer Services office). Shirt must
be tucked into pants.
2.
Khaki pants with belt: NO cropped, capris, shorts, cargo or baggy pants.
3.
Nails must be natural and if painted, not chipped and polish must be a conservative color.
4.
Picture and name visible. Secured on right shirt lapel.
5.
Clean, appropriate color, comfortable shoes (no open-toe shoes or flip-flops).
6.
Conservative jewelry.
7.
No perfume.
8.
Uniform must be neat and clean.
9.
Cell phone must be kept in pocket (on vibrate) and not visible or on belt holster.
10.
Act and dress professionally, following the Piedmont Healthcare’s Code of Conduct, Policies &
Procedures and Dress Code.
Rev. 1-21-2016
PLEASE RETAIN FOR YOUR RECORDS
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2016 JUNIOR VOLUNTEER PROGRAM
Zero Tolerance Policy
The following discipline issues will result in immediate termination from the Piedmont Newton Hospital
Youth Volunteer Program:

Theft of hospital, patient, employee, volunteer, or guest property.

Willful damage of hospital property.

Fighting or attempting bodily injury to any person on hospital property.

Public display of affection (PDA) of any type.

Immoral or lewd conduct.

Use of cell phone to text, check social media, or make non-emergency phone calls while on duty.


Refusal to perform assigned task-insubordination.

Walking off the assigned service without permission or leaving assigned area for extended period of time.

Sleeping while on duty.

Harassment of any form.

Coercing or harassing patients, employees, volunteers or guest.

Malicious practical joking /horseplay.

Reviewing, accessing or revealing confidential information.

Deliberate oral or physical abuse of a patient, guest, volunteer or employee.

Willful violation of safety regulations.

Possession of firearm or weapon on hospital property.

Consumption or possession of alcohol or drugs on hospital property.

Falsification of time and attendance records.

Smoking on hospital campus.

Inappropriate oral, written or physical conduct of a sexual or threatening nature.
Rev. 1-21-2016
PLEASE RETAIN FOR YOUR RECORDS
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