JUNIOR VOLUNTEER PROGRAM
JUNE 6 through AUGUST 14, 2016
 Must be 16 years old by August 31, 2016
 Return the attached application only on dates indicated
 Attend orientation on Sunday, June 5, 2016
 Complete 50 hours minimum during program
Herbert Looney
Manager – Volunteer Services
Methodist Stone Oak Hospital
1139 East Sonterra Blvd.
San Antonio, Texas, 78258
Herbert.Looney@MHSHealth.com
210-638-2107 office
210-912-2600 cell
2016 JUNIOR VOLUNTEER SUMMER PROGRAM
Dear Junior Volunteer:
Thank you for your interest in our Junior Volunteer Program at Methodist Stone Oak Hospital. To be
eligible you must be 16 years old on or before August 31, 2016. Our Junior Volunteer Program
kicks off on June 6, 2016 and runs for 10 weeks through Sunday, August 14, 2016. Space is limited
to 50 students so reserve a spot early by completing this application.
Bring your application to the volunteer office for an interview on the following dates:



Sunday, March 13th, noon to 4pm
Saturday, March 19th, noon to 4pm
Sunday, April 10th , noon to 4pm
These are the only dates that you can submit your application so make every effort to attend. The
program closes for the summer when we have 50 qualified applicants.
All first time Junior Volunteers will be asked to commit to volunteer a total of 50 hours during the 10
week program. Your area of service will be determined during your interview or at the time of
orientation. All requirements (volunteer application, background check, and TB test with employee
health,) must be completed on or before May 31st.
Juniors who volunteered in 2015 will be given first choice of the areas they worked previously. They
will have the same requirement to complete 50 hours within the 10 week program. Orientation and
background check will not be required, but a new TB test must be completed.
Orientation for all new junior volunteers will be held on Sunday, June 5th from 1pm until 4pm in
Classrooms 1 & 2, V.Benson Pavilion. Please ensure that you attend this orientation as there will be
only one for the Junior Volunteer Program. Orientation is mandatory to be able to volunteer.
Thank you again for your interest, I know we will have a rewarding experience this summer at
Methodist Stone Oak Hospital.
Sincerely,
Herbert Looney, Manager-Volunteer Services
Herbert.Looney@MHSHealth.com, 210-638-2107 office
APPLICATION FOR JUNIOR VOLUNTEERS
_________________________________________________________________________________________________
Name:
(Last)
(First)
(MI)
(Street/Apt #)
(City/State)
(Zip)
Address:
Primary Phone:
_____Cell Y N
Other Phone: (
)
Email Address: ____________________________________________________________________________________
Have you ever pled guilty or received deferred adjudication, probation, court ordered community supervision, or
been convicted of any crime (felony and/or misdemeanor) other than traffic citations?
YES
NO
If yes, explain:
Are you currently serving deferred adjudication, probation or court ordered community supervision?
YES
NO
If yes, explain:
Conviction of a crime is not an automatic bar to consideration for volunteering; however, persons convicted of
certain felonies and other crimes may be ineligible for volunteering in certain positions under Texas law.
EMERGENCY CONTACT
Name:
Relationship:
Phone:
_______
Please indicate your preference for volunteering, (days and times).
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8AM – 12PM
12PM – 4PM
As a volunteer, I understand that I will not be reimbursed for my services and I will regard my volunteer assignment as a serious
commitment. I will respect the confidentiality of all information available to me through my volunteer position. Should my conduct or
performance be deemed unsatisfactory for any reason, I agree to accept release from my volunteer assignment.
Signature of Applicant
Date
I hereby voluntarily give my permission for my child to enroll in the Junior Volunteer Program at Methodist Healthcare System, and to
take the necessary instructions for his/her work. I understand that Methodist Healthcare System is not to be held responsible in case of
accident. I also understand that my child will be required to adhere to safety standards and other regulations stated in Hospital policies,
including a TB skin test before volunteering.
Signature of Parent/Guardian
Date
For Office Use Only
Date of Initial Interview
Date Background Check completed
Date Employee Health completed
Date Orientation Completed
Completion of Volunteer Activities
MSOH Junior Volunteer Background Check Disclosure
In order for your application to be processed, please read the information below and acknowledge your acceptance by signing
and dating at the bottom. Your application cannot be processed until Methodist Healthcare System has received a signed and
dated Background Check Disclosure form. All background checks will be done online in the Volunteer Office.
APPLICANT NAME
First Name
Social Security
Number:
Middle Name
XXX – XX -
Last Name
(Last 4 numbers only, please)
Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may
be requested in connection with your application for volunteer services.
If your application is denied for volunteer services, either wholly or partly, because of information
contained in a consumer report, a disclosure will be made to you of the name and address of the
consumer reporting agency making such report. You will also receive a copy of the report and a
statement of your consumer rights.
I have read the above notice and understand what it means. I hereby authorize the procurement of a
consumer report for volunteer service purposes.
A consumer report may consist of employment records, educational verifications, licensure verification,
driving history, previous address and other public records relative to criminal charges. A credit report
will not be requested unless it is pertinent to the functions of the position for which you are applying.
Applicant Signature
Date of Birth:
Date
EMPLOYEE HEALTH VOLUNTEER REQUIREMENTS
Prior to the start of your volunteer services, you must be cleared by our Employee Nurse for TB testing.
You will need to bring the following documentation to her office when you present for the TB skin
testing:

Documentation of any previous TB skin testing within the last five years. MHS requires annual TB
tests for all volunteers.

Prior immunization records, to include:
o Documentation of prior vaccination for mumps, measles and rubella (MMR). You will need
documentation of 2 MMR shots.
o Documentation of the Hepatitis B vaccine if you have received the vaccine.
o Documentation of the VZV (Chicken Pox) vaccine.
OFFICE HOURS:
Monday through Friday
7:00AM – 3:30PM
Closed during lunch hour 12:00noon to 1:00pm
TELEPHONE:
(210) 638-2164
LOCATION:
1139 E Sonterra Blvd, San Antonio, TX 78258
2nd floor of the V. Benson Pavilion, room 240
TB SKIN TEST AUTHORIZATION (FOR THOSE UNDER AGE 18)
NEW _____
ANNUAL _____
EXPOSURE _____
NAME: __________________________________________________________________(PLEASE PRINT)
DATE TESTED: _____________________________
SITE: Right / Left Forearm (circle one)
APPLIED BY: ___________________________________________________________________
TEST RESULTS: ____________________________
DATE: __________________________
RESULTS READ BY: __________________________________________________, R.N.
RESULTS MUST BE READ WITHIN 48 TO 72 HOURS
HAVE YOU HAD CHICKEN POX: Yes: _____________ No: ____________
PLEASE SIGN AND RETURN THE FOLLOWING:
I hereby give permission for ____________________________________ to receive a TB Mantoux test. I
understand that the test will be administered by the Employee Health Nurse and there will be no cost for this
service.
_________________________
___________________________________________________
Date
Signature (Parent/Guardian required for Junior Volunteer)
EXCEPTIONS:
Volunteers who have tested positive for any reason are required to provide a copy of their x-ray report from
their physician stating that they have negative results.
Volunteers who are presently taking steroids are NOT required to take the test, but are required to provide a
statement from their physician stating they are taking steroids to excuse them from taking the TB test. (Steroids
result in a false negative test).