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Rev. 01-15-2018 1 | P a g e
Junior Volunteer Program
Information Packet
Piedmont Newton Hospital Volunteer Services
Summer 2018 June 5 – July 20
5126 Hospital Drive Covington, GA 30014 Tel: 770.788.6553 [email protected]
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January 2018
Dear Prospective Junior Volunteer and Parent or Guardian,
Thank you for your interest in participating in the Piedmont Newton Hospital Junior Volunteer Program. The program
runs for 7 weeks: from June 5 - July 20, 2018. It is for rising 10th, 11th & 12th grade students from Newton County as
well and the children and grandchildren of Piedmont Newton employees and volunteers.
To participate in this program, you must volunteer a minimum of 20 hours. This is achieved by working one, four-hour
shift per week. We ask you to consider carefully whether this time commitment will fit in with any family vacations, sport
commitments, part-time work schedules and any other summer obligations you may have. Your willingness and ability
to make a commitment to your volunteer assignment is crucial because the department in which you will be volunteering
depends on you.
The next page is a quick overview of the packet and the how, when, where and why to help you complete the application
process to be a Junior Volunteer.
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Piedmont Newton 2018 - Junior Volunteer Program The What, When and Why Information Sheet
WHAT: The Junior Volunteer Program is a summer volunteer program at Piedmont Newton Hospital for high school students who will be going into the 10th, 11th or 12th grades when school starts in the fall of 2018.
WHEN: What comes first and what comes next:
1. The program runs for 7 weeks: from June 5 - July 20, 2018. 2. To participate in this program, you must volunteer a minimum of 20 hours. This is achieved by working one, four-hour
shift per week. We ask you to carefully consider whether this time commitment will fit in with any family vacations, sport commitments, part-time work schedules and any other summer obligations you may have. Your willingness and ability to make a commitment to your volunteer assignment is crucial because the department in which you will be volunteering depends on you.
HOW: How do I become a Junior Volunteer? APPLICATION - The following forms must be returned by all applicants by Monday, March 5, 2018: a. Junior Volunteer Application b. Two letters of reference using the enclosed forms to be returned as specified on the forms. Returning Junior
Volunteers are also required to have two letters of reference. c. Signed “Junior Volunteer Agreement” d. Signed “Parental/Legal Guardian Agreement” e. Signed “Photo Authorization Contract for Junior Volunteer Program 2018”
3. INTERVIEWS - Interviews for first time Junior Volunteer Applicants will be held between 3:30 p.m. and 5 p.m. on
Tuesday, March 20th and on Thursday, March 22nd. There will also be interviews between 9 a.m. and 1 p.m. on Saturday, March 24th. Returning Junior Volunteers are required to interview and need to call the Volunteer Office to set up an interview appointment for the week of March 9th.
4. PROGRAM ACCEPTANCE - You will be notified by e-mail as to whether or not you have been accepted to the program.
Be sure the email address on your application is legible and is one you check often. Your assignment will be given to you at orientation.
5. Due to the limited number of available positions, final placement will be determined by lottery. The interview process
does not guarantee placement. AFTER ACCEPTANCE TO THE PROGRAM: 1. Upon acceptance to the program, you will receive information via email regarding the required tuberculosis screening
(TB Test), and Mandatory Orientation. Orientation classes are offered: Tuesday, June 5th from 9 a.m. to Noon and Thursday, June 7th from 1 p.m. to 4 p.m.
You will need to register by RETURN EMAIL OR PHONE CALL TO OUR OFFICE for one orientation class.
2. Uniform polo shirts will be distributed at orientation. A $20 uniform shirt fee will be collected at that time.
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WHY APPLY TO THE PROGRAM: The Junior Volunteer Program is a service to Piedmont Newton Hospital and provides an opportunity for students to gain exposure to a hospital environment, while contributing to their community. While volunteering with us, you may see your future- self in the healthcare field or you may learn that this is not your calling. While we sometimes want everyone to love the idea of a healthcare career, we know that either way, it is good to have new experiences, know what you are passionate about and start making plans concerning your career path. In short, this is a growing experience. Also, we will track your volunteer hours so they are available upon request later when you need them for college applications and for your resume.
If you have any questions or concerns, please contact the Volunteer Services Office at (770) 788-6553, or by e-mail at [email protected]. Our mailing address is: 5126 Hospital Drive, Covington, GA 30014. The Volunteer Services office is located at 4152 Mill Street and is staffed Monday-Friday from 8 a.m. – 4:30 p.m. Sincerely, A. Lisa Brooks Auxiliary Services Specialist
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TABLE OF CONTENTS
Application …………………………….………………………………………………………………………6
All Applicants - Reference 1 ……….………………………………………………………………………….7
All Applicants - Reference 2 …………………………………………………………………………………..9
Junior Volunteer Agreement…………..………………………………………………………………………10
Parental/Legal Guardian Agreement: …………………………………………………………………………11
JuniorVolunteer Dress Code ………………………………………………………………………………….12
Zero Tolerance Policy…………………………………………………………………………………………13
Photo Authorization Contract for Junior Volunteer Program ……..………………………………………….14
Special Note: We thank you in advance for printing neatly on all the enclosed forms. We are asking for a lot
of information with phone numbers and email addresses and sometimes it’s hard to decipher handwriting and
our guessing what was written leads to trouble contacting you when needed. We appreciate your extra
efforts!
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2018 JUNIOR VOLUNTEER
Application
Check One: New Junior Volunteer Returning Junior Volunteer
(print) Last Name: First Name: Middle Initial:
Street Address: City: State: Zip:
Home Phone: Cell Phone: Sex: M F Birthdate:
/ /
Age:
E-mail: School Attending: Class of:
Do you have any family member who is an employee or a volunteer at Piedmont Newton Hospital?
Yes No
- If yes, please list name(s), relationship(s) and work area:
How did you hear about the Junior Volunteer Program at Piedmont Newton Hospital?
Do you have any physical limitations requiring special accommodations in order for you to volunteer?
Yes No If yes, please explain:
Interest/Skills List any prior work experience or volunteer service:
List foreign languages that you write or speak:
List any other special skills such as, keyboarding, computer skills, sign language, etc.:
Do you have an area of interest in the medical field? Please tell us about it:
FOR OFFICE USE ONLY
Date rec’d.
_____/____/_____
RETURN TO VOLUNTEER SERVICES OFFICE
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Scheduling Check shift and days you are available for volunteer assignments (Note: exact hours vary by department needs).
Weekday Mon Tue Wed Thu Fri
Morning
Afternoon
We realize you may not know all of your summer plans, but please list the dates you will be unable to work this summer
due to family vacations, driver’s education, school, band camp, sports, etc. (To participate in this program, you must
volunteer a minimum of 20 hours by working one, 4-hour shift per week.)
Dates Unavailable:
Parental Information and Agreement
Name of Parent/Legal Guardian (print neatly)
Street Address: City: State: Zip:
Home Ph: Work Ph: Cell:
E-mail:
All Junior Volunteers must be covered by a family/medical hospitalization policy, which must be listed below. Should
it become necessary to seek medical attention in the emergency room, your insurance will be utilized.
In case of emergency, notify:
Name: Relationship: Phone No:
In the event I cannot be reached, permission is hereby granted to treat my child, _______________________________,
for any problem that might occur while on duty as a volunteer.
Print:
Parent/Legal Guardian Signature: Date: / /
Insurance Information:
Policy Holder’s Name:
Policy No:
Company:
I hereby certify that the answers on this application are true and correct and that any omission of facts or misrepresentation,
misleading or false information on my part will be grounds for dismissal as a volunteer. I will abide by all rules and
regulations established. I understand that at any time I fail to abide by the established rules and regulations, I will forfeit
my privilege to serve as a volunteer and may be discharged without warning or notice. Acceptance as a volunteer is
contingent upon satisfactory references and verification of the information submitted. I authorize that all employers,
schools or references thus contacted shall be released from all liability in answering inquiries related to my application.
/ /
/ /
Junior Volunteer Signature Date Parent/Legal Guardian Signature Date
RETURN TO VOLUNTEER SERVICES OFFICE
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2018 JUNIOR VOLUNTEER
New and Returning Applicants – Reference #1 – School Counselor
Due in the Volunteer Office on or before March 5, 2018
Volunteer’s Last Name: First Name: Date: / /
School Attending:
Reference’s Name:
(Printed)
First & Last Name: Contact Number:
Dear School Counselor,
The individual named above has applied for the JUNIOR VOLUNTEER PROGRAM at Piedmont Newton
Hospital. Your assistance is requested in evaluating the applicant with regard to the following qualities. Candid
completion of this information will give us an opportunity to properly review his/her qualifications and assign them
to an appropriate area if all qualifications are satisfactorily met.
Personal Appearance:
Maturity:
Ability to get along with others:
Attitude toward taking directions:
Sense of
Responsibility:
Dependability:
Additional
Comments:
Print Name:
Signature: Date:
To assure confidentiality and proper processing of this information, please complete this form and return to student in a sealed envelope or scan and email directly to the A. Lisa Brooks at [email protected] . If you have any questions, please call the Volunteer Office at (770) 788-6553.
RETURN TO VOLUNTEER SERVICES OFFICE
Rev. 01-15-2018 9 | P a g e
2018 JUNIOR VOLUNTEER PROGRAM
New and Returning Applicants – Reference #2 – Personal
Due in the Volunteer Office on or before March 5, 2018
Volunteer’s Last Name: First Name: Date: / /
School Attending:
Reference’s Name:
(Printed)
First & Last Name: Contact Number:
Dear (Please circle one) Principal / Teacher / Coach / Minister or Adult Friend:
The individual named above has applied for the JUNIOR VOLUNTEER PROGRAM at Piedmont Newton
Hospital. Your assistance is requested in evaluating the applicant with regard to the following qualities. Candid
completion of this information will give us an opportunity to properly review his/her qualifications and assign them
to an appropriate area if all qualifications are satisfactorily met.
Personal
Appearance:
Maturity:
Ability to get along with others:
Attitude toward taking directions:
Sense of Responsibility:
Dependability:
Additional Comments:
Signature:
Print Name: Date:
To assure confidentiality and proper processing of this information, please complete this form and return to student in a sealed envelope or scan and email directly to Lisa Brooks at [email protected] If you have any questions, please call the Volunteer Office at (770) 788-6553.
RETURN TO VOLUNTEER SERVICES OFFICE
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2018 JUNIOR VOLUNTEER PROGRAM
Junior Volunteer Agreement
As a Junior Volunteer at Piedmont Newton Hospital, I promise to:
1. Obtain, complete and submit all required information necessary for processing by Monday, March 5,
2018 to Piedmont Newton Hospital Volunteer Services, 5126 Hospital Drive, Newton, GA 30014.
2. Interviews will be held between 3:30 p.m. and 5 p.m. on Tuesday, March 20th , Thursday, March 22nd
and Saturday, March 24th from 9 a.m. to 1 p.m. YOU must call to schedule your interview
appointment. We will do our best to accommodate the appointment time requested. (Junior Applicant –
We ask that you please make this call.)
3. Obtain a TB (Tuberculosis) Test at the Occupational Health Services Office free of charge through
Piedmont Newton Hospital, and update my tetanus shot, if necessary.
4. Attend a 3-hour mandatory orientation and training meeting for all new and returning Junior Volunteers.
You can schedule this for Tuesday, June 5th from 9 a.m. to 12 p.m. or Thursday, June 7th from 1 p.m.
to 4 p.m. at the hospital. You will attend only one class and will need to reserve a spot.
5. Attend one orientation class and serve a minimum of 20 hours between June 5 – July 20. (All new and
returning Junior Volunteers are required to serve at least one, 4-hour shift per week.
6. Ensure that written, advance notification of time to be missed for family vacations, driver’s education,
school, band camp, sports, etc. is included in the application.
7. You will be required to find a substitute if you are unable to volunteer on your scheduled date. We will
provide a schedule and sub list at orientation.
8. Be dependable and fulfill your work assignments. Always conduct yourself with dignity and courtesy.
Provide your highest quality work.
9. Be punctual and sign in and out at designated location or online.
10. Read and comply with the “Zero Tolerance Policy.”
11. Consider all information you hear, either directly or indirectly, concerning a patient or a member of the
hospital staff to be confidential.
12. Act and dress professionally, following the Piedmont Healthcare’s Code of Conduct, Policies &
Procedures and Dress Code.
13. Be committed to enjoying this learning experience by serving patients, visitors, staff and fellow
volunteers in a friendly, courteous manner.
14. Return your Identification Badge at the end of the program.
15. Check your email regularly for messages from the Volunteer Services Office as all information will be
sent electronically. All email will be sent to the address you provide on page 4 of the application.
Print Name:
Junior Volunteer Signature: Date: / /
E-Mail: Phone:
RETURN TO VOLUNTEER SERVICES OFFICE
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2018 JUNIOR VOLUNTEER PROGRAM
Parental/Legal Guardian Agreement
1. I hereby permit my child, __________________________________________________ to join the Junior
Volunteer Program at Piedmont Newton Hospital. I understand the importance of responsibility and will
assist my child in complying with the program’s rules and regulations. I will assume responsibility for
his/her transportation.
2. I have read and understand the “Zero Tolerance Policy.”
3. I agree that my student’s identification badge will be turned in at the end of the program.
4. In the event of a medical emergency, I permit the physicians in the Emergency Department of Piedmont
Newton Hospital to treat my student.
5. I understand that in order for my student to participate in the program, all-necessary information must be
obtained, completed and submitted no later than Monday, March 5, 2018.
6. Interviews will be held between 3:30 p.m. and 5 p.m. on Tuesday, March 20th, Thursday, March 22nd
and Saturday, March 24th from 9 a.m. to 1 p.m. I agree to attend the interview with my student as a
mandatory part of the application process. Please note: THE STUDENT needs to call to schedule their
interview appointment. We will do our best to accommodate their appointment time request.
7. I understand my student will be required to pay $20.00 for the uniform shirt.
8. I hereby give permission and I will accompany my student to receive a TB (Tuberculosis) Test at the
Occupational Health Services office located on the 2nd floor of the main hospital building.
Tel: (770) 385-7895. Screenings and tests are provided by Piedmont Newton Hospital at no charge.
9. I understand that my child is required to attend one orientation class and serve a minimum of 20 hours from
June 5 – July 20. Written, advance notification of time to be missed for family vacations, driver’s
education, school, band camp, sports, etc. must be included in Application Form. Last minute schedule
changes are very disruptive to the hospital staff and volunteer office. The Volunteer Office staff is not
responsible for adjusting your child’s schedule so that they can obtain the necessary hours.
10. I understand that all information will be communicated electronically to my child’s e-mail and that I will
need to check their email regularly for messages.
Parent/Legal Guardian
Signature:
Print Name: Date: / /
E-mail: Phone:
Please Print Neatly!
RETURN TO VOLUNTEER SERVICES OFFICE
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2018 JUNIOR VOLUNTEER PROGRAM
Junior Volunteer Dress Code
1. Red polo shirt with the hospital logo (to be purchased at the Volunteer Services office). Shirt must
be tucked into pants.
2. Khaki pants with belt: NO leggings, cropped, capris, shorts, cargo or baggy pants. No denim.
3. Nails must be natural and if painted, not chipped and polish must be a conservative color.
4. Piedmont Newton Hospital ID badge must be worn at all times when at the hospital volunteering
with the picture and name visible.
5. Clean, appropriate color, comfortable shoes (no open-toe shoes or flip-flops).
6. Conservative jewelry.
7. No perfume.
8. Uniform must be neat and clean.
9. Cell phone must be kept in pocket (on vibrate) and not visible or on belt holster.
10. Act and dress professionally, following the Piedmont Healthcare’s Code of Conduct, Policies &
Procedures and Dress Code.
PLEASE RETAIN FOR YOUR RECORDS
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2018 JUNIOR VOLUNTEER PROGRAM
Zero Tolerance Policy
The following discipline issues will result in immediate termination from the Piedmont Newton Hospital
Youth Volunteer Program:
Theft of hospital, patient, employee, volunteer, or guest property.
Willful damage of hospital property.
Fighting or attempting bodily injury to any person on hospital property.
Public display of affection (PDA) of any type.
Immoral or lewd conduct.
Use of cell phone to text, check social media, or make non-emergency phone calls while on duty.
Refusal to perform assigned task-insubordination.
Walking off the assigned service without permission or leaving assigned area for extended period of time.
Sleeping while on duty.
Harassment of any form.
Coercing or harassing patients, employees, volunteers or guest.
Malicious practical joking /horseplay.
Reviewing, accessing or revealing confidential information.
Deliberate verbal or physical abuse of a patient, guest, volunteer or employee.
Willful violation of safety regulations.
Possession of firearm or weapon on hospital property.
Consumption or possession of alcohol or drugs on hospital property.
Falsification of time and attendance records.
Smoking on hospital campus. We are a smoke free campus.
Inappropriate verbal, written or physical conduct of a sexual or threatening nature.
PLEASE RETAIN FOR YOUR RECORDS
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TITLE OF EVENT: Junior Volunteer Program 2018
Photo Authorization Contract for Junior Volunteer Program 2018
Authorization for Use/Disclosure of Protected Health Information
For Piedmont Healthcare Marketing and Public Relations' Purposes ONLY
For: Piedmont Newton Hospital, 5126 Hospital Drive, NE, Covington, GA 30014
I, __________________________________________________, hereby request and authorize an affiliate of Piedmont Healthcare, Inc.: (Initial Desired Options)
___N/A__ To permit: ________________________________to be present during my medical care on: ___________
(Print observer name) (Date)
__N/A__ To use any information provided by me, my family or the medical staff related to my story as a patient of a
Piedmont Healthcare affiliate in connection with any publications (including but not limited to newspapers, television and/or radio broadcasts, audio/video recordings, drawings and sketches, books, brochures, magazines, videotapes, motion pictures, websites or other publicly distributed materials) in such manner and at such times and in such places as Piedmont Healthcare, Inc. shall determine without restriction at its sole discretion.
_ _ (Initial here) To take and use photographs, video recording, slides and any comment made verbally or recorded
or made by me for publications or advertising purposes (included but not limited to newspapers, television and/or radio broadcasts, audio/video recordings, drawings and sketches, books, brochures, magazines, videotapes, motion pictures, websites or other publicly distributed materials) in such places as Piedmont Healthcare, Inc. shall determine without restriction at its sole discretion.
__N/A__ To release my name and condition as determined by my nurse/physician upon request from the media and/or
release the signed and dated statement attached to this form. I understand the purpose for this use or disclosure of my information is for Piedmont Healthcare, Inc. educational, public relations and/or marketing purposes. I hereby release and forever discharge Piedmont Healthcare (including, without limitation, its affiliates and their respective officers, directors, employees, medical staff and agents) from any and all manner of claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the disclosure and the public exposure resulting from such use or disclosure of my information. Junior Volunteer Full Name: ___________________________________________________________________________ Junior Volunteer Date of Birth: ______________________________ Phone # (Home): _______________________ (Work): _____________________ (Cell): ________________________ E-mail Address: (please print clearly!) _________________________________________________________________ Current Address: _________________________________________________________________________________
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I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of the information and may then no longer be protected by the federal privacy regulations. I understand that unless otherwise limited by state or federal regulations, I may revoke this Authorization at any time by presenting my revocation in writing except to the extent that Piedmont Healthcare, Inc. has taken action in reliance on this Authorization. A revocation form may be obtained from the Piedmont Healthcare Marketing and Public Relations Department. The completed revocation must be presented to the Piedmont Healthcare Marketing and Public Relations Department. I further understand that this Authorization is specific to the information agreed to above and for the purpose written above. Piedmont Healthcare, Inc. shall not condition treatment on the receipt of this specific Authorization. I further understand that this Authorization is valid until revoked by me or my legal personal representative in writing, noting that information used or released prior to the receipt of the written revocation cannot be revoked. Patient or Legal Representative Signature _______________________________________________________ ____________________________________________ ___________ _________ Junior Volunteer Name (PRINT) Date Time
This box will be initialed by a Piedmont Healthcare, Inc. representative if the use or disclosure is for a marketing function
for which a Piedmont Provider receives direct or indirect remuneration from a third party.
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