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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