Teen Volunteer Application

Volunteer Services Department

TEEN Volunteer Application

Name:  _______________________________    Date: _______________________________

Address: ______________________________    City: ____________ State: ______________

Date of Birth: __________________________    So Security No: ______________________

In case of emergency, notify: ___________________________ Relationship: _____________

Home Phone:____________________ Work Phone: _______________ Cell Phone: ________

Name of School:___________________________Present Grade:(Circle)  8   9   10   11   12

Graduation Year: _________________  Career Plans: ________________________________

Hobbies, Accomplishments, Skills, Interests, Foreign Languages, Sign Language:

____________________________________________________________________________

Previous Volunteer Experience: ___________________________________________________

What type of volunteer work would you prefer? _____________________________________

How often would you like to volunteer? ____________________________________________

On which days are you available to volunteer? _______________________________________

List names and phone numbers of two personal references (not related): 

Name: ______________________________    Phone: _________________________________

Name: ______________________________    Phone: _________________________________

What influenced you to apply for volunteering at Baptist Health Corbin? __________

_____________________________________________________________________________

I am between the ages of 14-18 and maintain a "C" or above average in school.  I have a sincere desire to serve my community through volunteering.

_________________________________________    __________________________________

Signature of Applicant                                            Date

For questions or comments, please call the Volunteer Office at 606-523-8768.

Teens will need provide a letter from their school Principal or Guidance Counselor on school letterhead verifying good attendance, grades, discipline and character.  Return the completed application to the Volunteer office.  Your application will be reviewed by the Membership Committee.  If you are accepted into our program, we will contact you for further information or to schedule an interview.

I agree to allow my son/daughter ______________________________ to serve as a TEEN Volunteer at Baptist Health Corbin.  I fully understand that in the course of his/her duties, my son/daughter may be permitted to enter patient areas of the hospital.

I release, discharge and relieve Baptist Health Corbin from all claims whatsoever of any nature arising our of and as a result of his/her service at Baptist Health Corbin.

I give permission for him/her to take the TB skin test and/or chest x-ray, which is required of all Volunteers.

___________________________________________    ________________________________

Parent/Guardian Signature                                            Date

Our records require proof of health insurance of the above named person and for those Volunteers driving to the hospital, proof of auto insurance.  Please provide the following information below:

Name of Health Insurance Company: _______________________________________________

Name of Insured: _______________________________________________________________

Policy Number/Group Number: ____________________________________________________

Auto Insurance Company: ________________________________________________________

Policy Number: _________________________________________________________________