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McCullough-Hyde Memorial Hospital

Teen Volunteer Application Form

McCullough-Hyde Memorial Hospital

Teen Volunteer Application Form

Please make sure that before filling out this application, you have already submitted the Pre-volunteer background inquiry release.

Today's Date:**

First Name:**

Last name:**

Middle Name:

Street Address:**

City:**

State:**

Zip Code:**

Age:**

School you attend:**

Present Grade:**

Name of Parent(s)/Guardian:**

Home Phone:**

Work Phone:**

Email:**

Person to be contacted if you should become ill while on duty:

Name:**

Relationship to you:**

Address:**

Home Phone:**

Work Phone:

Your Family Physician:**

Phone Number:

Have you volunteered or worked for McCullough-Hyde in the past?*

*YesNo

Days you are able to volunteer:**

Time of day you can volunteer:**

Reason for wanting to volunteer:

Previous volunteer experience:

Previous work experience:

Education/career interests and goals

Hobbies, skills, activities and interests

Please give any additional information you feel may be pertinent to your application:

Have you ever been convicted of a crime (Considered only as it relates to fitness to perform the volunteer position being sought)?*

*YesNo

References

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1. Name:**

Phone:**

Address:**

Email:*

2. Name:**

Phone:**

Address:**

Email:

The information I provided is accurate and correct to the best of my knowledge. I give permission to McCullough-Hyde Hospital to check my references**

Furthermore, I understand that my signature indicates approval for MHMH to perform a background check and/or request fingerprints. Please be aware that McCullough-Hyde Memorial Hospital, Inc. is not obligated to provide volunteer placement, nor are you obligated to accept a position.

Electronic Signature:**

Date:**

Opportunities for volunteers are provided without regard to creed, race, national origin, age or sex. *State Senate Bill 187 requires us to notify you that you may at any time be subject to a criminal records check. McCullough-Hyde is a smoke free and tobacco free campus. This position is not an employee position and is not paid for the services rendered. Influenza vaccines are mandatory and documentation should be submitted to volunteer services by November 1 of each year. TB testing (tuberculosis) is required before volunteering. This can be done in our Immunology Clinic free of charge. Call 513.524.5566 for hours. Also, a copy of your immunization records (showing MMR and Hepatitis B) will be collected from you before volunteering.