Junior Volunteer Profile
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Last Name:

First Name:

M Initial:

Formal:

Select Mr. Mrs. Miss Ms.

Preferred Greeting:

Present Street Address:
City:		State:		Zip Code:
Home Telephone:
Email Address:

Date of Birth:

Are you a U.S. Citizen? Select Yes No

Employer: (indicate none if you are not employed)
Emergency Contact:
Phone Number:
Relationship:
Referral: Select Volunteer School Advertisement Publicity
School:
Expected Graduation Date:
Career Plans:
Available Days To Work:
Available Hours To Work:
How Often: Select Daily Twice a week Once a week	Have you ever been convicted of a felony? Select Yes No
If Yes, please explain:
My son/daughter has my approval and support to serve as a junior volunteer at Community General Hospital. I also give my consent to have an initial Rubella titer (a blood test) to determine immunity against measles, an initial PPDs (tuberculin skin test), and a PPD annually thereafter.
Parent or Guardian Signature:
Date:

Junior Volunteer Profile
Please note - all fields need to be completed before the information is transmitted.

Tell us why you want to volunteer

Why have you decided to volunteer at Community-General Hospital?

Please list your school activities:

Please list your activities outside school:

Tell us about YOU. What are your personal strengths? What do you do well?

Please give us 2 examples that show that you are a caring and respectful person:

Please give us 2 examples that show that you are a dependable person:

How do you plan to balance your personal activities with your commitment to volunteering?

Do you plan to work?	Select Yes No
Do you plan to participate in sports?	Select Yes No
Do you have vacation plans?	Select Yes No
What weeks will you be away?

Have you discussed your plans to volunteer with your parents - do they understand that you have agreed to volunteer 8 hours per week (50 hour minimum) this summer?

What transportation arrangements have you made to volunteer?

Do you have any special skills you would like to use while you volunteer?

Computer
Clerical
Leadership
Other

Is there a particular type of volunteer work at CGH that interests you?

What day(s) of the week do you plan to volunteer?

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Requirements and Expectations

1. Medical Clearance
   
   
   • A recent physical
   • Current immunization record
   • We will complete 2 tests at Community General Hospital: a PPD (tuberculin skin test) and Rubella titer (a blood test)
   
   
   
2. Student Obligations
   
   
   • NYS Working Papers from your high school guidance counselor
   • Hospital Orientation Program
   • $15 deposit for the volunteer jacket
   • Assignment Training
   • Absences and Vacation reported by the student
     • Junior volunteers report anticipated absences (not the parent- except in an emergency).
     • Unexcused or frequent absences disrupt the quality of care to patients and are not acceptable.
   • School Year - 4 hours per week for the semester and a minimum of 50 hours.
   • Summer Program - 8 hours per week during July and August and a minimum of 50 hours.

   

Please note - all fields need to be completed before the information is transmitted.