STUDENT VOLUNTEER APPLICATION - NCH Healthcare System

Returning student application
deadline: April 5, 2013
New student applicant deadline:
April 9, 2013
STUDENT VOLUNTEER APPLICATION
Please read carefully, print clearly and answer all questions. It is a requirement to complete at least 40
hours for the summer; volunteering at least three, four-hour shifts a week. Please ensure you do not
foresee missing more than two weeks during the program which runs from June – August, 2013.
Incomplete or inaccurate applications will be rejected. We will contact you to schedule your interview.
At which location do you prefer to volunteer?
Are you a returning NCH VolunTeen?
NCH Downtown NCH North Naples Yes No
PERSONAL/CONTACT INFORMATION:
Name:
Last First MI
Mailing Address:
Apt#
City:
Home Phone:
Zip Code:
Cell Phone:
E-mail Address:
Current Age: __________
If 14, will you be 15 prior to June 7, 2013? (circle one): YES / NO
EDUCATION:
School you are currently attending:
Current Grade Level: G.P.A. (unweighted, minimum of 3.0):
(Winter Term)
VOLUNTEER REFERRAL METHOD:
How did you first hear about the NCH Volunteer Services Program?
NCH Employee or NCH Board Member - Name:_____________________________________________
Current/Former Volunteer - Name: ______________________________
Physician
Internet School Other: _____________________________

EMERGENCY CONTACT INFORMATION:
Name of Emergency Contact:
Relationship:
Street Address (if different from above):
Apt. No.: City: Zip:
Home Phone: Cell: Work:
Physician’s Name:
Phone:
APPLICANT’S COMMENTS:
Why do you want to be an NCH volunteer?
____________________________________________________________________________________
What are your areas of interest? __________________________________________________________
What do you enjoy doing in your free time? _____________________________________________
REFERENCES: (Please list two references. The references may not be related to you and must be over 18
years of age.)
1. Name: Phone:
Relationship to Student:
2. Name: Phone:
Relationship to Student:

COUNSELOR / TEACHER’S COMMENTS: Please give detailed information on student’s performance.
Note: If you are homeschooled, please have one of the listed references complete this portion.
How long have you known the applicant and in what context?
___________________________________________________________________________________
What are the applicant’s strengths and weaknesses as you perceive? _____________________________
____________________________________________________________________________________
What are the first two words that come to mind when you think of the applicant and why?
_____________________________________________________________________________________
Please give an example of when you have witnessed leadership qualities from the applicant?
______________________________________________________________________________________
______________________________________________________________________________________
Please provide examples of when the applicant has displayed several or all of these traits: academic
achievement, respect, compassion, taken initiative, and self-confidence.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Counselor/Teacher Signature:_________________________________________Date:_______________

WORK EXPERIENCE, SKILLS, AND ACTIVITIES:
Work Experience: ________________________________________________________________________
Computer Skills: _________________________________________________________________________
Languages: _____________________________________________________________________________
Volunteer Experience/Community Affiliation: _________________________________________________
Recreation/Hobbies: ______________________________________________________________________
VOLUNTEER PREFERENCES:
Patient Contact Non-Patient Contact Information/Clerical
Are you able to push a wheelchair: Yes No
Are you able to be on your feet for four hours: Yes No
When are you available to volunteer?
Work Shift: Mornings Afternoons Evenings Flexible
Work Days: Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Flexible
If you are participating in the program, will you be able to fulfill the requirement of completing at least 40
hours for the summer; volunteering at least three, four-hour shifts a week (circle one)? YES / NO
Please detail expected dates of absence such as vacation, summer camp, or other activities:
Please describe your mode of transportation: ________________________________________________

BACKGROUND INFORMATION:
NCH Healthcare System conducts criminal record checks. Falsification or failure to disclose complete
information will disqualify you from volunteer service. A conviction does not necessarily disqualify you
from volunteer service.
Have you ever been employed by NCH Healthcare System or any of its affiliates in any capacity?
Yes / No (circle one)
If yes, when hired?
If yes, what department?
Other than a misdemeanor traffic violation, have you ever been charged with or convicted of any crime?
Yes / No (circle one)
If yes, please explain and provide the location (county and state):
Are you charged with an unresolved criminal charge? (Are you charged with a crime that has not yet
resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?)
Yes / No (circle one)
If yes, explain and provide the location (county and state):
Are you currently on probation?
Yes / No (circle one)
Date
Your Signature

To perform my duties as an NCH Student Volunteer:
STUDENT VOLUNTEER CONTRACT
1. I will review and abide by the policies and procedures stated in the NCH Healthcare System
Student Volunteer Handbook and Standards of Excellence.
2. I will consider my volunteer assignment as a commitment. If I am unable to work my volunteer
shift, I will arrange for a substitute volunteer who is trained and assigned to the same service
area. If I cannot arrange for a substitute, I will notify the Director/Coordinator of Volunteer
Services within 24 hours in advance of my shift, if possible. I understand that I may be
terminated from the program should I be absent from my volunteer shift two times in a row
without proper notification.
3. I understand and am able to fulfill the requirement to work at least 40 hours for the summer;
volunteering at least three, four-hour shifts a week.
4. I will hold all information as confidential concerning patients, families, staff members, physicians
and volunteers.
5. I will make my service professional in all ways. I will conduct myself with dignity, courtesy and
have consideration for others.
6. I understand that the following may result in immediate dismissal: Breach of confidentiality; Lack
of honesty; Failure to complete work; Personal verbal attacks.
7. I will not make or receive personal phone calls (land line or cellular) or text while volunteering.
8. I understand that only patients are to be seated and/or transported in the hospital wheelchairs.
9. I understand that I must be in compliance with the dress code.
PARENT/GUARDIAN AGREEMENT
1. I understand that the NCH Healthcare System reserves the right to dismiss my child’s services as
a volunteer if the action is in the interests of the hospital and/or my child. Dismissal could result
from failure to comply with hospital rules and regulations or inappropriate personal conduct,
attitude or appearance.
2. I give my consent for my son/daughter to submit this application to join the NCH Healthcare
Student Volunteer Program.
3. I give consent for the NCH Healthcare System to administer to my child and monitor an annual
TB skin test.
SIGNATURES
Parent/Guardian Signature
Student Applicant Signature
Please return completed application and required documents to:
Volunteer Office
Volunteer Office
NCH Healthcare System
NCH Healthcare System
Downtown Naples Campus
North Naples Hospital Campus
350 7 th Street North 11190 Health Park Blvd.
Naples, FL 34102 Naples, FL 34110
(239) 624-3410 (239) 552-7703

Confidentiality Agreement
I, _________________________, a volunteer at NCH Healthcare System, understand that state and federal
law and the NCH Healthcare System’s Information Security Policy require confidentiality and privacy
protections for hospital records. I further understand that in connection with my duties I may have access to
confidential information such as patient records (clinical, financial, and social date), business records,
committee reports, physical office records, incident reports, information about fellow employees, and other
proprietary information.
If I am given computer access through a sign-on identification code and password, I will use it solely to
obtain access to information necessary to perform my job functions. I shall not disclose my sign-on
password to anyone nor will I attempt to learn another user’s password. I understand that any lost or
disclosed password should be reported to my immediate supervisor for follow-up procedures to correct and
reassign password as necessary.
I acknowledge that I have a responsibility to safeguard Confidential Information and to see that it is
disclosed only to those properly authorized to obtain the information. I further agree to use such
Confidential Information only in the course of my duties with the NCH Healthcare System.
I understand that my failure to maintain strict confidentiality of such Confidential Information will subject
me to immediate discharge, civil sanctions, and criminal penalties according to Florida law.
As VolunTeen’s parent/guardian, I certify this information has been reviewed with my child. Please note,
HIPAA/Confidentiality information will be thoroughly reviewed at the NCH VolunTeen orientation.
_________________________
Signature of VolunTeen
________________________
Date
_________________________
Signature of Parent/Guardian
________________________
Date

STUDENT VOLUNTEER APPLICATION CHECKLIST
Student Volunteer Application completed and signed by student.
Student Volunteer Contract, signed by parent/guardian and student.
Confidentiality Agreement, signed by parent/guardian and student.
Copy of most recent report card with proof of un-weighted GPA of 3.0 or higher.
Available to complete at least 40 hours for the summer; volunteering at least three, four-hour shifts a
week.
Signed teacher/counselor written recommendation (included in application).
Thank you. The Volunteer Office will contact you to schedule an interview in April or May.