Download Mountainside Hospital - Hackensack UMC at Pascack Valley

Department of Volunteer Services
Junior Volunteer Application Packet
Dear Prospective Volunteer:
Please read this letter carefully for the requirements of becoming a volunteer at HackensackUMC at Pascack
Valley. The forms in this packet include an application, a health form and a return envelope.
Requirements:

Minimum age is 14 years old.

Must be able to attend a 2-hour training session.

Must have health form completed and signed by a family physician.

Must have one (1) letter of reference from a teacher or guidance counselor.

If you are chosen to volunteer, you will be required to have two tuberculosis tests.

Must be able to devote a minimum of 75 hours and three to five months consecutive service in a
calendar year to be entitled to a letter confirming hours volunteered.
Contact Information:

Jenna Lowe, Volunteer and Marketing Specialist
Phone: 201-383-1019
Email: [email protected]
Possible duties performed by junior volunteers include patient transport, errand running, clerical duties,
envelope stuffing, filling water pitchers, patient visitor.
IMPORTANT NOTE: Application packets must be received by our office with all documentation COMPLETE
AND TOGETHER including the application, health form signed by a physician, any applicable immunization
records and the letter of reference from a teacher or a guidance counselor. Incomplete applications will not be
accepted. We look forward to receiving your completed application.
Sincerely,
Jenna Lowe
JUNIOR VOLUNTEER APPLICATION
Date: ______________________________
Miss
Name: ______________________________
Nick Name:
Address:
________
Mr.
________
_______________________________________
____________________________________________________________________________________
Date of Birth:
__________________________
Social Security #:
__________________________
Phone Number:
__________________________
School Grade:
__________________________
Cell Number:
___________________________
E-Mail:
_____________________________________
School you attend/address: ________________________________________________________________________
Do you have past experience as a volunteer? (If yes, please explain):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please circle the type(s) of volunteer tasks that interest you.
clerical/non-typing
filing
filling water pitchers
transporting patients
answering phones
directing visitors
collating paperwork
retail sales
delivering items
Days and hours that you are available to volunteer: ____________________________________________________
Physician’s name, address and phone number:
____________________________________________________
__________________________________________________________________________________________________
Do you have a family member who presently works for HUMC at Pascack Valley Hospital? _________________
If yes, please list name, their relationship to you and their location: _______________________________________
__________________________________________________________________________________________________
Applicant’s Signature: _______________________________________
Date: __________________________
Parental Consent:
My child, __________________________ is at least 14 years of age or older, and has my consent to serve as a
junior volunteer at HUMC at Pascack Valley Hospital. He/she is in good health and upon completion of the
required training course, will be responsible to complete their volunteer assignment. The Manager of
Volunteer Services will determine the volunteer assignment during an interview.
Parent Signature
___________________________________________
Date
Relationship
____________________
________________________________
Daytime Phone #
__________________________
Immunization Record for
Volunteers
Name: _______________________________________________ DOB: ___/___/___
Address: ______________________________________________________________
Telephone Number: _____________________________________________________
IMMUNIZATION
Hepatitis B: (Must have one of the following)
A. Proof of having all three doses of the Hepatitis B Vaccine._____
B. Documentation of a positive Hepatitis Surface Antibody (HBsAb) _____
C. Vaccine Waiver Form: (see attached)_____
Rubeola (Measles):
A. Rubeola Titer – demonstrate immunity with attached titer results
Rubella (German Measles):
A. Rubella Titer– demonstrate immunity with attached titer results
Mumps:
A. Mumps Titer: – demonstrate immunity with attached titer results
Varicella Titer: (Must have one of the following)
A. Proof of two doses of varicella vaccine, 4-8 weeks apart _____
B. Varicella Titer: – demonstrate immunity with attached titer results
Tuberculosis Skin Testing (TST)*:
A. No signs and symptoms of active TB and Two-step TST (2 Mantoux
tests given within 1-3 weeks of each other) within the past 12 months,
OR
B. Single TST if one documented negative TST within the past 12 month,
YES/DATES
NO
OR
C. Prior documentation of negative results of 2 Mantoux tests performed
within 12 months preceding work at MH.
D. Adequate two-step TST followed by annual testing.
If positive TST :
E. Documentation of test result & negative chest X-ray in the past 6
months, &.
F. Documentation that individual does not have active tuberculosis
infection.
G. If latent tuberculosis infection, documentation of adequate treatment if
individual was treated.
If evaluated with blood assay for Mycobacterium tuberculosis (BAMT),
those results should be submitted instead of TST.
Contagious Diseases:
This individual named on this form is free from contagious disease. Yes ______ No ______
===================================================================
_____________________________________________________
Signature of Volunteer
_________
Date
_____________________________________________________
Signature of health practitioner (REQUIRED)
_________
Date
_____________________________________________________
Name & Title of PV staff who reviewed record
Hepatitis B Vaccination Declination
I, ________________________________________, understands that due to my
print
occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B
virus (HBV) infection. However, I have declined to be vaccinated for hepatitis B. I understand that by declining
this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.
___________________
Date
__________________________________________
Signature