Dear Youth Volunteer:
Thank you for your interest in the Saint Luke’s Health System (SLHS) Volunteer Program! We have an
engaging program filled with a variety of opportunities for those 14 -17 years of age.
Please note: not all SLHS locations have Youth Volunteer Programs. Call the facility of choice to
ascertain if a Youth Volunteer program is offered; if confirmed, schedule an interview/orientation.
Bring this completed profile packet to the interview. The interview will include a discussion about our
program, available opportunities, and expectations. A parent/guardian is encouraged to accompany you
to the interview.
To become a youth volunteer, you must complete the documents listed below/attached.
_______Profile (parent/guardian signature required for youth in school 14 -17 yrs).
_______Physician Form (parent/guardian/physician signatures required). Return form via mail or fax to
the appropriate SLHS Facility.
A TB test and an Influenza Vaccination (within the past 12 months) is required. These tests can
be acquired from your physician or Health Department. SLHS can provide the TB test at no cost
if the youth is accepted to volunteer. The Physician can include the TB and Influenza
Vaccination documentation on the Physician Form, if available.
_______Volunteer Reference Forms (2)
SAINT LUKE’S HEALTH SYSTEM CARE FACILITIES
Saint Luke’s Cushing Hospital
711 Marshall St.
Leavenworth KS 66048
913.684.1310
Saint Luke’s East Hospital
100 NE Saint Luke’s Blvd.
Lee’s Summit MO 64086
816.347.4930
Saint Luke’s North Hospital-Barry Road
5830 NW Barry Road
Kansas City MO 64154
816.880.6083
Saint Luke’s Hospital of K.C.
4401 Wornall Road
Kansas City MO 64111
816.932.2448
Saint Luke’s South Hospital
12300 Metcalf Avenue
Overland Park KS 66213
913.317.7405
Saint Luke’s Hospice/Hospice House
3100 Broadway, Suite 1000
Kansas City, MO 64111
816.756.1160
Hedrick Medical Center
2799 N. Washington St.
Chillicothe, MO 64601
660.646.1480
In submitting this profile, I understand that I will receive no remuneration for the volunteer services I provide. I agree to
maintain confidentiality concerning all guest information and adhere to the policies and procedures that have been
established by Saint Luke’s Health System. I understand, as a hospital volunteer, I am required to provide TB Test and
Influenza Vaccination documentation and I give permission to Saint Luke’s Health System to contact my physician,
references, and to conduct a personal background check. I understand SLHS no longer selects individuals who use any
tobacco, nicotine, e-cigarettes or vaping products and I represent and agree I do not currently and will not use any of
said products as a volunteer of SLHS. I do understand that I cannot smoke or use said products on campus or on parking
lots of the facility. Non-compliance of this policy is grounds for immediate dismissal of volunteer responsibilities I hereby
certify that the information contained in this profile is true, complete and correct. I understand that all information
contained in my volunteer profile will be kept confidential.
Vs 6.14.3
PROSPECTIVE YOUTH VOLUNTEER PROFILE
Information About You
First Name
Street
City
Home Ph#
Email
Date of Birth
Physician Phone
Middle Name
Last Name
Apt. #
Zip Code
State
Cell Ph#
Age
Social Security # (xxx -12-3456)
(last 6 digits only)
Physician Name
Information About Your Parent(s)/Guardian
I live with my (check all that apply)
Parent/Guardian Name
Home Ph#
Cell Ph#
Parent/Guardian Name
Home Ph#
Cell Ph#
Parent
Parent
Guardian
Work Ph#
Email
Work Ph#
Email
Your Current Activities
Name of School
School Ph#
School Activities
Employer and Job (if employed)
Typical Work Schedule
Volunteer Experience
Other school, work, church or other activities/experience
Last Grade Completed
Volunteering at Saint Luke’s Health System
Please write a paragraph stating the reasons you want to volunteer (use reverse page if needed).
Vs 6.14.3
YOUTH VOLUNTEER PROFILE
Volunteering at Saint Luke’s Health System, continued
How did you hear about our volunteer program?
Your skills
Babysitting
Computers
Mentoring
Other:
Your language(s)
English
Spanish
French
German
Other:
Your Interests
Clerical
Patient Contact
Errands
Nursing
Child Care
Other:
When are you available to volunteer? Check all that apply.
Sunday
Monday
Tuesday
Wednesday Thursday
Morning
Afternoon
Evening
Friday
Saturday
Please list two Personal References (not related to you)
Name
Street/City/Zip
E-mail:
Name
Street/City/Zip
E-mail:
Do you have any of these health issues? Check all that apply.
Allergies
Arthritis
Asthma
Back Problems
Diabetes
Epilepsy
Fainting Spells
Foot Problems
Hearing Problems
Heart Problems
Hepatitis
High Blood Pressure
Mental Illness
Tuberculosis
Other Infectious Conditions
Do you have any limitations which would affect the type of volunteer position assigned?
No
Yes Explain
List medications taken regularly
At Which Saint Luke’s Health System Location do you wish to volunteer?
Saint Luke’s Cushing Hospital
711 Marshall St.
Leavenworth KS 66048
913.684.1310
Saint Luke’s East Hospital
100 NE Saint Luke’s Blvd.
Lee’s Summit MO 64086
816.347.4621
Saint Luke’s North Hospital-Barry Road
5830 NW Barry Road
Kansas City MO 64154
816.880.6083
Saint Luke’s Hospital of K.C.
4401 Wornall Road
Kansas City MO 64111
816.932.2005
Saint Luke’s South Hospital
12300 Metcalf Avenue
Overland Park KS 66213
913.317.7405
Saint Luke’s Hospice/Hospice House
3100 Broadway, Suite 1000
Kansas City, MO 64111
816.756.1160
Hedrick Medical Center
2799 Washington St.
Chillicothe, MO 64601
660.646.1480
Vs 6.14.3
YOUTH VOLUNTEER COMMITMENT:
As a Youth Volunteer for Saint Luke's Hospital, I understand I will receive no remuneration for my services. I give permission to
contact references if necessary. Should I be unable to volunteer as scheduled, it is my responsibility to notify Volunteer
Services. I understand that I will receive no remuneration for the volunteer services I provide. I agree to maintain
confidentiality concerning all guest information and adhere to the policies and procedures that have been established by Saint
Luke’s Health System. I understand I am required to provide TB Test and Influenza Vaccination documentation and my parent
give permission to Saint Luke’s Health System to contact my physician, references. Cell phone use will be limited while
volunteering. I understand SLHS no longer selects individuals who use any tobacco, nicotine, e-cigarettes or vaping products
and I represent and agree I do not currently and will not use any of said products as a volunteer of SLHS. I do understand that I
cannot smoke or use said products on campus or on parking lots of the facility. I hereby certify that the information contained
in this profile is true, complete and correct. I understand that all information contained in my volunteer profile will be kept
confidential. Non-compliance to comply with policy, these commitments and expected behaviors in the Youth Volunteer
Program will result in termination from my duties as volunteer.
YOUTH SIGNATURE:______________________________DATE:__________________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PARENT/GUARDIAN PERMISSION
In signing this document, I give permission for the youth named on this profile to participate in the Saint Luke's Health System
Youth Volunteer Program and other facility sponsored activities. I verify the youth is 14-17 years of age and the information on
this profile is correct. I understand that all of the profile packet’s information will be kept confidential and is for office or
emergency use only.
I am responsible for the purchase of a uniform. I take responsibility for the youth’s transportation, prompt arrival and
departure for his/her scheduled shift. I understand it is the responsibility of the youth to notify Volunteer Services of changes.
I will provide TB Test and Influenza Vaccination documentation from a physician, Health Department or give permission for the
youth to receive a TB skin or blood test administered by SLHS (no cost). I am responsible for the provision of a completed
Health Statement & Physician Form. In the event of illness or injury and I am not available, the physician listed on this profile
will be notified for treatment. Should the physician be unavailable, I give permission for the youth to receive appropriate
emergency care.
DATE:________________PARENT/GUARDIAN:___________________________________
(Required for students in school 14 - 17 yrs)
RELATIONSHIP:________________________
NONDISCRIMINATION AND EQUAL OPPORTUNITY STATEMENT
It is the policy of Saint Luke's Health System not to discriminate in admissions or access to, or treatment or employment in its program and
activities, or in the granting, maintaining, upgrading and withdrawal of physician staff privileges for any unlawful reason, such as race, color
national origin, sex, age, or handicap in violation of Section 504 of the Rehabilitation Act and applicable regulations. Responsible employee:
Administration Director of Civil Rights - 816-932-3820
*********************************************************************************************F
OR OFFICE USE ONLY
INTERVIEW DATE/TIME ________________BY___________
[ ] Physician Form [ ] TB Documentation / [ ] 2 nd Screening (as required) [ ] Flu Shot [ ] Orientation/Video
[ ] I.D. Badge
[ ] Uniform/Shirt Received
[ ] Fees Rec’d
[ ] 1st [ ] 2nd Reference Received
Assignment_____________/___________/__________________________________________________________
(Day)
(Time)
(Position
REMARKS:_____________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________Starting Date: ____________________Time:__________________
Vs 6.14.3
PROSPECTIVE YOUTH VOLUNTEER PHYSICIAN’S FORM
Youth Name _____________________________SS# (if req’d by Physician)_______________
I authorize release of the following information to Saint Luke’s Health System.
____________________________________________________
Prospective Volunteer’s Parent / Legal Guardian Signature
Specify location/s below
________________________
Date
Hedrick Medical Center
Fax# 660-214-8136
Saint Luke’s Cushing Hospital
Fax# 913-758-1894
Saint Luke’s East Hospital
Fax# 816-347-4626
Saint Luke’s North Hospital
Fax# 816-880-6358
Saint Luke’s Hospital
Fax# 816-932-3888
Saint Luke’s South Hospital
Fax# 913-317-7404
Saint Luke’s Hospice/Hospice House
Fax# 816-756-2596
---------- This section to be completed by Physician ---------Please Fax information requested to the location/s specified above.
______
I see no medical reason why this person should not volunteer.
______
This person should volunteer with the following restrictions.
_________________________________________________________________________
______
This person should not be a volunteer in a healthcare facility.
TB documentation (last 12 months) is required for all volunteers. (The TB Test and Influenza
Vaccination can be acquired by the Physician or Health Department. The Saint Luke’s System Hospital
you choose to volunteer can provide the TB test.)
______
Date of TB test (last 12 months) if available
or
______
Date of chest x-ray indicating free of active Tuberculosis (last 12 months)
If x-ray is contraindicated, please comment (below) on follow-up & whether this person
will pose hazard to others.
______
Date of Influenza Vaccination within last 12 months.
______________________________________________
__________________________________________
Signature of Physician
Printed Name of Physician
_______________________________
Address/ City/State/Zip
____/____/____
Phone
___/___/___
Date
Vs 6.14.3
YOUTH VOLUNTEER PERSONAL REFERENCE
_____________________________________________ has applied to volunteer at a Saint
Luke’s Health System facility and has given you as a personal reference. Please complete this
form and return to the perspective youth volunteer. Thank you for your help.
Coordinator/ Youth Volunteers
VOLUNTEER REFERENCE
Name of Reference
__________________________________________
Relationship to Applicant (not a relative)_____________________________________________
How long have you known the applicant? ___________________________________________
Explain how the applicant demonstrates they are
responsible/dependable?__________________
______________________________________________________________________________
Why would you recommend the applicant as a volunteer for Saint Luke’s Health System? _____
______________________________________________________________________________
______________________________________________________________________________
Additional Comments
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Reference ___________________________________________ Date _________
Telephone #/ Email
_____________________________________________________________________________
(Optional)
Vs 6.14.3
YOUTH VOLUNTEER PERSONAL REFERENCE
_____________________________________________ has applied to volunteer at a Saint
Luke’s Health System facility and has given you as a personal reference. Please complete this
form and return to the perspective youth volunteer. Thank you for your help.
Coordinator/ Youth Volunteers
VOLUNTEER REFERENCE
Name of Reference
__________________________________________
Relationship to Applicant (not a relative)_____________________________________________
How long have you known the applicant? ___________________________________________
Explain how the applicant demonstrates they are
responsible/dependable?__________________
______________________________________________________________________________
Why would you recommend the applicant as a volunteer for Saint Luke’s Health System? _____
______________________________________________________________________________
______________________________________________________________________________
Additional Comments
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Reference ___________________________________________ Date _________
Telephone #/ Email
_____________________________________________________________________________
(Optional)
Vs 6.14.3