VolunTEEN Application Rev 3-15-13 - Rex Healthcare

VolunTEEN Application4420 Lake Boone Trail Raleigh, North Carolina 27607 (919) 784-3165(919) 784-7034 (FAX) www.rexhealth.comE-Mail volunteer.services@rexhealth.comI am apply ing f or (check one):-Summer Program (Application must be in by the Summer deadline date)-Af ter School Program (Application must be in by the Af ter School deadline date)NOTE: Application deadline dates are found on our web site:www.rexhealth.comHav e y ou applied f or either the Summer or Af ter School program bef ore? YESNODate:Social Security #: (Last 4 digits)Middle Name:Last Name:First Name:Pref erred Name:Street Address:City : State: Zip Code:Telephone (Home):Email:Telephone (Work):Telephone (Cell):Birthdate: School Attending: Graduation Year:MISCELLANEOUS REQUIRED INFORMATION (PLEASE ANSWER ALL QUESTIONS CAREFULLY.)Special Skills:Clubs, Activ ities, Special Honors:Hav e y ou ev er pled guilty or been conv icted of a crime other than minor traf f ic v iolations:Yes No If y es, explain:Are y ou related to any one employ ed by or who v olunteers at Rex? Yes NoIf y es, giv e name, department, and relationship:If y ou are working with a special program f or credit (club, court, etc.) please list:(organization) (ref erence person) (phone)Are y ou interested in a health related career?VolunTEEN CommitmentI hereby apply to become a VolunTEEN at Rex Healthcare, to abide by the VolunTEEN ethics to keepall patient inf ormation strictly conf idential and to comply with all rules and regulations of Rex Healthcare.Signature of VolunTEENDateRev ision 2/18/08, 3/10/08,9/1/10, 7/15/11, 2/22/13, 3/15/13 1 of 5 S:/Volunteer/Applications/VolunTEEN Application

VolunTEEN Application4420 Lake Boone Trail Raleigh, North Carolina 27607 (919) 784-3165(919) 784-7034 (FAX) www.rexhealth.comE-Mail volunteer.services@rexhealth.comPARENT/LEGAL GUARDIAN INFORMATIONMother/Legal GuardianFather/Legal GuardianNameHome Phone:Business Phone:Cell Phone or Pager No.:E-mailNameHome Phone:Business Phone:Cell Phone or Pager No.:E-mailStreet AddressStreet AddressCity , State, ZIPCity , State, ZIPCONSENT OF PARENT/LEGAL GUARDIANMy child has my consent to serv e as a Rex HealthcareVolunTEEN. I will support the responsibilities my child accepts as a VolunTEEN.I realize that ref erences may be solicited and I giv e my permission f or y ou to contact any of theref erences prov ided. Further, I hereby release all persons/institutions f rom liability or damages as aresult of ref erence checks.Signature of Parent/Legal GuardianDateI understand that an initial Tuberculosis skin test is required to allow my child to v olunteer. Thereby I giv emy permission f or the staf f at Rex Healthcare to administer an initial Tuberculosis Skin Test on my child.Signature of Parent/Legal GuardianDateI understand that a pre-v olunteer drug screening is required to allow my child to v olunteer. Thereby , I giv emy permission f or the staf f at Rex Healthare to administer a pre-v olunteer drug screening on my child._________________________________________Signature of Parent/Legal Guardian__________________DateRex Healthcare does not discriminate in hiring or employment on the basis of race,color, sex, religion, national origin, disability, or age.Rev ision 2/18/08, 3/10/08,9/1/10, 7/15/11, 2/22/13, 3/15/13 2 of 5 S:/Volunteer/Applications/VolunTEEN Application

VolunTEEN Application4420 Lake Boone Trail Raleigh, North Carolina 27607 (919) 784-3165(919) 784-7034 (FAX) www.rexhealth.comE-Mail volunteer.services@rexhealth.comVolunTEEN QuestionnaireApplicant's Name:(Last) (First) (Middle)1 Tell us why y ou want to v olunteer?2 Tell us about YOU. What are y our personal strengths? What do y ou do well?3 We are looking f or people who are caring and respectf ul. Please giv e us two examples thatdemonstrate that y ou are such a person.4 Our hospital and the patients rely on people who are dependable. Please giv e us two examplesthat demonstrate y ou are a dependable person.5 You are required to f urnish references from two (2) people. Completed f orms should be mailedto Rex Volunteer Serv ices. Use the f orms on the next 2 pages f or that purpose.Thank you!Rev ision 2/18/08, 3/10/08,9/1/10, 7/15/11, 2/22/13, 3/15/13 3 of 5 S:/Volunteer/Applications/VolunTEEN Application

VolunTEEN Reference Form4420 Lake Boone Trail Raleigh, North Carolina 27607 (919) 784-3165(919) 784-7034 (FAX) www.rexhealth.comE-Mail volunteer.services@rexhealth.comTo be completed by an adult (at least 21 years old) who is not applicant's legal guardian or relative.Note to reference form completer : Thank y ou f or assisting the staf f at Rex Healthcare in its selectionof the most committed, capable and mature teenagers f or participation in out VolunTEEN Program.Please return completed ref erence in a sealed env elope directly to:VOLUNTEER SERVICE OFFICE, 4420 Lake Boone Trail, Raleigh, NC 27607.Applicant's Name:Ref erence's Name:Phone:May we contact y ou f or f urther inf ormation on the abov e named applicant? Yes No1 How long hav e y ou known the applicant and in what capacity ?2 Realizing that the selected applicants will be working in a complex medical env ironment, whatqualities can y ou identif y in the applicant that will help us make an appropriate selection?(examples: dependable, mature, courteous)3 How well will the applicant be able to work independently ? With Others?4 Would y ou like y our comments to remain conf idential? Yes No5 Do y ou recommend the applicant f or a v olunteer position? Please check only one:highly recommended recommended some reserv ations sorry , cannot recommendSignature:Date:Thank you for your assistance!Rev ision 2/18/08, 3/10/08,9/1/10, 7/15/11, 2/22/13, 3/15/13 4 of 5 S:/Volunteer/Applications/VolunTEEN Application

VolunTEEN Reference Form4420 Lake Boone Trail Raleigh, North Carolina 27607 (919) 784-3165(919) 784-7034 (FAX) www.rexhealth.comE-Mail volunteer.services@rexhealth.comTo be completed by an adult (at least 21 years old) who is not applicant's legal guardian or relative.Note to reference form completer : Thank y ou f or assisting the staf f at Rex Healthcare in its selectionof the most committed, capable and mature teenagers f or participation in out VolunTEEN Program.Please return completed ref erence in a sealed env elope directly to:VOLUNTEER SERVICE OFFICE, 4420 Lake Boone Trail, Raleigh, NC 27607.Applicant's Name:Ref erence's Name:Phone:May we contact y ou f or f urther inf ormation on the abov e named applicant? Yes No1 How long hav e y ou known the applicant and in what capacity ?2 Realizing that the selected applicants will be working in a complex medical env ironment, whatqualities can y ou identif y in the applicant that will help us make an appropriate selection?(examples: dependable, mature, courteous)3 How well will the applicant be able to work independently ? With Others?4 Would y ou like y our comments to remain conf idential? Yes No5 Do y ou recommend the applicant f or a v olunteer position? Please check only one:highly recommended recommended some reserv ations sorry , cannot recommendSignature:Date:Thank you for your assistance!Rev ision 2/18/08, 3/10/08,9/1/10, 7/15/11, 2/22/13, 3/15/13 5 of 5 S:/Volunteer/Applications/VolunTEEN Application