Junior Volunteer Application Form

First Name:

Last Name:

Phone:

E-mail:

Address:

City:

State:

Zip:

Name of Parent or Guardian:

Father Business Address:

Phone:

Mother Business Address:

Phone:

School Presently Attending:

Grade:

Graduation Year:

GPA:

Previous volunteer experience:

Hobbies/Sports:

Clubs/Memberships:

When you think of volunteering, what kinds of things interest you?

What do you hope to gain from your volunteer experience?

Please indicate the hours that you will be available:

As a student volunteer, I understand that I am required to:

• Be over 16 years of age
• Maintain at least a 2.5 (C+) GPA
• Have a written consent form from a parent or guardian
• Have a referral from a school counselor or principal
• Follow the hospital rules and regulations
• Works one regularly scheduled shift per week
• Commit to one semester (marking period)
• Contact the Volunteer Manager immediately regarding any absences from duty. Failure to do so may result in termination from the volunteer program.

Signature:

Date:

Parents:
I understand the Rules and Regulation(s) for my teen to participate in the Junior Volunteer Program at New London Hospital and hereby give my consent and support.

Signature:

Date:

FOR OFFICE USE ONLY
Date of Application Received: ______/_______/_______      

Orientation Date: ______/_______/_______

Service Area: _______________________________________

Shift: ________________________

Department Supervisor: __________________________________________