NORTHSIDE HOSPITAL FORSYTH VOLUNTEEN PROGRAM

January 2013 Dear Applicant, Northside Hospital-Forsyth will be offering a Volunteen Program this summer for teen volunteers between the ages of 15 (must be 15 by January 1, 2013) and 18. This will be an exciting eight week program beginning June 2, 2013 and ending on July 27, 2013. The number of teens we can accommodate is limited. Our objectives of our Volunteen program are to conduct an excellent educational program, to develop an interest in volunteer services for our participants and to provide an opportunity for students to experience the total healthcare environment. The teens accepted for membership in the Volunteen Program will be trained and supervised by either a Northside Hospital-Forsyth Auxiliary member or a hospital staff member. Read the following program requirements before filling out an application: The mandatory orientation is Wednesday, May 29, 2013. This is the only orientation date. Submit an application only if you: o can attend the entire mandatory orientation on May 29 th, o can commit to volunteering at least seven of the eight weeks, and o can attend your first volunteer assignment the week of June 2 nd. The application packet includes: The application page 1 Medical history page 2 Immunization Information Form page 3 Agreement form page 4 Absence schedule form page 5 Forms for two letters of recommendations pages 6 and 7 (Required from teachers counselor, clergy or employer, NOT RELATIVES and must be included in the application packet.) The completed packet must be returned in a sealed envelope to Dianne Baker by Thursday, February 28, 2013. Only completed packets will be considered for acceptance in the program. Please mail your completed application packet to: Dianne Baker, Volunteen Coordinator Northside Hospital-Forsyth 1200 Northside Hospital Drive Cumming, GA 30041 Dianne Baker Volunteen Coordinator 770-844-3390 Dianne.baker@northside.com

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NORTHSIDE HOSPITAL FORSYTH VOLUNTEEN PROGRAM 2013 CHECKLIST FOR APPLICATION

Following instructions is an important step to becoming a Volunteen and will show us that you are responsible. This checklist is to ensure that you are clear as to the requirements for applying to the Volunteen Program. 1. ________ Read through the application packet with your parents and check your summer commitments for any conflicting dates. 2. ________ Fill out the application neatly and completely. 3. ________ Ask the people who are filling out your recommendation forms to place the form in a sealed envelope and have them sign across the seal of the envelope. Unsealed envelopes will not be accepted and your application will be considered incomplete. Include the sealed envelopes with your application packet when you submit your application. Note: please have teachers return the forms directly to YOU for submission with you packet. 4. _______ Please place all forms in an envelope to ensure that all materials stay together. Your packet is complete with the following materials: a. Application form b. Medical history c. Immunization records d. Agreement form e. Absence request form f. Two letters of Recommendation

5. _______ Mail your completed packet to: Dianne Baker, Volunteen Coordinator Northside Hospital Forsyth 1200 Northside Hospital Drive Cumming, GA 30041 6. ________ DEADLINE DATE: Thursday, February 28, 2013 by 4 p.m. THERE WILL BE NO EXCEPTIONS TO THIS DEADLINE DATE.

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AUXILIARY VOLUNTEEN SUMMER PROGRAM APPLICATION

June 2nd July 27th PRINT PLAINLY - COMPLETE ENTIRE APPLICATION PLEASE USE UPPER CASE LETTER TO COMPLETE THE APPLICATION A VOLUNTEEN is a teenager 15-18 years of age (must be 15 by January 1 of current year) who serves Northside Hospital-Forsyth without salary. The teen works within the hospital under the supervision of specified personnel and is accountable to the Northside Hospital Forsyth Director of Volunteer Services and Volunteen Chairman of the Auxiliary. Attendance in the entire mandatory orientation (May 29, 2013) is required prior to volunteering in the hospital. Completed applications must be received no later than February 28, 2013. DATE________________________ NAME________________________________________________________________________ (Last) (First) (Middle Initial) Preferred Name: _____________________________ Age: ________ Address__________________________________________________Phone________________ City____________________________________State__________________Zip Code_________ Email address _______________________________________ Cell ______________________ Birthdate___________ School__________________________________Year in School______ Parent/Guardian_________________________________ Work Phone_____________________ In case of emergency, notify_______________________________________________________ (Name) (Daytime Phone) Relationship _______________________________

PLEASE LIST YOUR FAMILY PHYSICIAN AND HIS/HER MAILING ADDRESS Physicians name________________________________________________Phone__________ Address_______________________________________________________________________

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VOLUNTEEN MEDICAL HISTORY

Name__________________________________________________________ (Last, First, Middle Initial) Sex________

Home Address___________________________________________________________________ Phone_________________ School_____________________________ In Case of Emergency, please notify: ______________________________________________________________________________ Phone________________________________Relationship_______________________________ The Administration at Northside Hospital-Forsyth needs written consent for Volunteers to receive emergency treatment in the event of a serious illness or accident and you cannot be contacted. PARENT/LEGAL GUARDIANS APPROVAL_________________________________________ RELATIONSHIP__________________________________ DATE__________________ MEDICAL HISTORY 1. List all drugs and medications the applicant is presently taking. Drug Dosage ______________________________ ______________________________ ______________________________ 2. 3. ______________________________ Birth date: ________________ Age: ________

Indicate: Freshman, Sophomore, Junior, Senior

List any allergies:____________________________________________________ List any serious injuries, illnesses, surgeries or disabilities ___________________ __________________________________________________________________

PARENT/LEGAL GUARDIANS APPROVAL_________________________________________ DATE: _______________________

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NORTHSIDE HOSPITAL FORSYTH AUXILIARY VOLUNTEEN PROGRAM

IMMUNIZATION RECORDS Applicants name: _________________________________________

Applicants birth date: _______________________________________

WE MUST HAVE THIS DOCUMENTATION TO PROCESS YOUR APPLICATION As part of the application process in our Volunteen Program, proof of the teen applicant having two (2) doses of measles, mumps, and rubella (MMR) vaccines since his or her first birthday is required. These records can be obtained from the pediatrician or school immunization records. Staple a copy of your official immunization record to this form.

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NORTHSIDE HOSPITAL FORSYTH VOLUNTEEN PROGRAM - AGREEMENT FORM

PARENT/GUARDIAN AGREEMENT The Volunteen program at Northside Hospital-Forsyth is a group of young people giving their time and talents to community service in a hospital setting. There are many responsibilities expected of teenagers serving others in a healthcare environment. This program will provide many learning experiences and hours of enjoyment. Both parent and teen should understand the seriousness in adhering to the roles and regulation set forth. I hereby permit my son/daughter ______________________________________ to submit this application to join the Volunteen Program of Northside HospitalForsyth. If accepted into the program, I realize the responsibilities and will cooperate with my son/daughter to comply with the rules and regulations. I will assume the responsibility for his/her transportation. Signature of Parent/Guardian ____________________________________________ Date: _______________ VOLUNTEENS AGREEMENT I hereby elect and agree to be covered by Northside Hospital-Forsyth Workers Compensation Program for any accident or injury sustained during the course of my volunteer service to Northside Hospital-Forsyth. I acknowledge that I am not considered an employee for any other purposes and am not entitled to any of the other benefits available to employees. If accepted into the Volunteen Program, I agree to abide by the requirements and regulations and serve the required number of hours. I promise to consider as confidential all information which I may hear either directly or indirectly concerning a patient or a member of the hospital staff. Applicants Signature _______________________________________________ Date: ______________

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NORTHSIDE HOSPITAL FORSYTH

VOLUNTEEN PROGRAM
ABSENCE REQUEST FORM
Orientation: Wednesday, May 29, 2013 Program Dates: June 2, 2013 July 27, 2013 NAME: ___________________________________________ DATE: ___________

BECAUSE CONTINUITY IS SO IMPORTANT TO OUR PROGRAM, PLEASE DO NOT APPLY TO OUR SUMMER PROGRAM IF YOU PLAN TO MISS MORE THAN ONE SHIFT DURING THE EIGHT WEEK PROGRAM OR CANNOT ATTEND THE FIRST WEEK OF THE PROGRAM. 1. I will be available the first week of the summer program? 2. Do you have any absences planned during our summer program? If yes, please complete the third question. YES YES NO NO

3. What is the date of your planned absence? ____________________________

PLEASE SIGN THIS FORM EVEN IF YOU DO NOT PLAN TO HAVE ANY ABSENCES DURING OUR SUMMER PROGRAM. APPLICANTS SIGNATURE ______________________________________ PARENT/GUARDIANS SIGNATURE ______________________________________ DATE: _________________ DATE _________________

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Required Letter of Recommendation I

Dianne Baker, Volunteen Coordinator Northside Hospital Forsyth 1200 Northside Forsyth Drive Cumming, GA 30041 Date_________________________

Dear Ms Baker: _________________________________ has applied for membership in the 2013 Volunteen Program at Northside Hospital Forsyth. I would like to make the following comments on this students Maturity___________________________________________________________ Behavior__________________________________________________________ Dependability______________________________________________________ Ability to follow directions____________________________________________ Additional comments_______________________________________________

__________________________________________________________________________________________ __________________________________________________________________________________________

I recommend that __________________________________ (be/not be) considered for the Volunteen Program at Northside Hospital Forsyth. ________________________________________________ Signature of person submitting the recommendation _______________________________________________ Title of person submitting the recommendation ______________________________________________ Telephone number Please place this form in a sealed envelope and sign across the seal of the envelope before you return this form to the applicant.

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Required Letter of Recommendation II

Date_________________________ Dianne Baker, Volunteen Coordinator Northside Hospital Forsyth 1200 Northside Forsyth Dr Cumming, GA 30041 Dear Ms Baker: _________________________________ has applied for membership in the 2013 Volunteen Program at Northside Hospital Forsyth. I would like to make the following comments on this students Maturity___________________________________________________________ Behavior__________________________________________________________ Dependability______________________________________________________ Ability to follow directions____________________________________________ Additional comments_______________________________________________

_________________________________________________________________ _________________________________________________________________ I recommend that __________________________________ (be/not be) considered for the Volunteen Program at Northside Hospital Forsyth. ________________________________________ Signature of person submitting the recommendation ________________________________________ Title of person submitting the recommendation ________________________________________ Telephone number Please place this form in a sealed envelope and sign across the seal of the envelope before you return this form to the applicant.

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