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Junior Volunteer Application

Applicants must by 14 years of age AND have completed 9th grade.
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First Name
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Last Name
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Email
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Telephone
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Address1
Address2
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City
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State
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Zip
  

Your Information

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Name of School
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Grade
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Date of Birth

Emergency Notification Information

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Name
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Relationship
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Phone (daytime)
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Phone (evening)

Volunteer Availability

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Days you will be able to volunteer:






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Hours you are able to work each day:

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Area of interest:

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Please check the department(s) in which you are interested in working:








Essay

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In 300 words, describe why you are interested in volunteering at the hospital, what skills you would like to gain from your volunteer experience, and also what skills you have to offer that will benefit the patients and staff at the hospital.
(Allowed extensions: *.doc, *.docx, *.pdf)

School Counselor Recommendation

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Name of School Counselor
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Phone
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I attest that my school counselor has recommended me for participation in the Carroll Hospital Center Junior Volunteer Program.

Note: Please download a School Counselor Recommendation Form from our website. This form must be completed and returned to us no later than March 31, 2014.

Parent/Guardian Permission

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Parent/Guardian Name
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Phone
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I attest that my parent/guardian has given me permission to participate in the Carroll Hospital Center Junior Volunteer Program and understands the responsibility of this commitment and will cooperate to ensure that I have transportation and adhere to the standards, policies and values of Carroll Hospital Center.

Note: Please download a Parent/Guardian Permission Form from our website. This form must be signed and returned to us no later than March 31, 2014.
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I agree to present the following verification prior to attending the Volunteer Orientation Session:

1. A physician or health department vaccination record showing immunization with live vaccine at or after 15 months of age and a second immunization to Rubella (German Measles) and Rubeola (Measles).

2. Documentation from a physician or health department of a current PPD (test for tuberculosis). Note: You will need to contact your physician or a health care provider for this test.

3. Signed permission slips to participate in the Junior Volunteer Program from your school counselor and parent/guardian.

Volunteer Agreement

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As a volunteer at Carroll Hospital Center, I agree to:

1. Attend the orientation program for Junior Volunteers.
2. Be punctual and conscientious in the fulfillment of my duties.
3. Commit to a minimum of 4 hours a week with a minimum total of 40 hours upon completion of my volunteer work at Carroll Hospital Center.
4. Maintain confidentiality concerning all patients and hospital business.
5. Conduct myself with dignity, courtesy, and respect for others.
6. Adhere to the hospital dress code.
7. Comply with all standards, policies, and values of Carroll Hospital Center.

Your Signature

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Print Signature
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Date