Summer 2015 Junior Program application

Junior Volunteer Application
(For High School & College Students)
Requirements:
-Applicant must be at least 14 years old by June 1.
-Applicant must be available to volunteer at least one 4 hour shift per week (Mon-Fri) from June 15 – August 7
-Applicant must complete and submit application before May 1, 2015 to the Imaging/Volunteer Department in 1 of 3 ways:
-Email:
-Fax:
-USPS:
Stephanie.guerra2@hcahealthcare.com
281-348-8349
Kingwood Medical Center
Attn: Imaging/Volunteer Dept.
22999 US Hwy 59 North
Kingwood, TX 77339
Pre-selection:
-Upon review of applications, candidates will be contacted via email to schedule an interview.
-After pre-selections are complete, top applicants will receive emails indicating they’ve been selected to become Junior
Volunteers.
Post-selection:
-Once selected, students must complete two TB skin test within a week apart; these are free and administered at the hospital.
** 2014 Jr. Volunteers will not be required to repeat the TB Skin Test.
-An email will be sent with times & dates for students to have their hospital ID badge photo made. Replies to this email are
required and must include the student’s preferred size for a uniform shirt (polo-style).
**2014 Jr. Volunteers can wear their shirts from last year if they’re in good condition.
-A mandatory orientation will be held the beginning of June; exact date, time and location TBD.
-Uniform payment of $25 is due before start of program via cash or check – made out to Kingwood Medical Center.
Applications are due to the hospital’s Radiology Department by May 01, 2015.
******No Exceptions******
Please Print:
Check one:
 New to the Jr Volunteer program at Kingwood Medical Center
 Returning Jr Volunteer
If returning, what was the last year you participated in our program? ____________
Your Name: _______________________________
Today’s Date: ________________________
Name of Parent or Guardian: ________________________________________________________________
Address: ________________________________________________________________________________
City: _____________________________
State: _________
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Zip: __________________
Birth Date: ________________
What will your age be as of June 1? ___________
Best phone number at which to reach you (the student):
____________________________________
Best email address at which to reach you (the student):
____________________________________
Best phone number at which to reach your parent/guardian:
____________________________________
Best email address at which to reach your parent/guardian:
____________________________________
Name of your school during 2015-2016 school year:
____________________________________
What grade were you in during the 2015-2016 school year?
8th
9th
10th
11th
12th
Why do you want to be a hospital volunteer? _________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Can you devote at least 4 hours/week to volunteering with us this summer?
YES
NO
Do you have any interest in extending your volunteering into the school year?
YES
NO
Is there anything else you’d like us to know about you? ___________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
*********************************************************************************************************
__________________________________
Signature of Applicant
__________________________________
Signature of Parent or Guardian listed on pg 1 (if applicant is younger than 18 at time of completion)
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