Community

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Teen Volunteen Application

Personal Information

First Name
Last Name
Age
Address
City
State
Zip Code
Phone
Emergency Phone
School Phone
Email Address

Parent Information

Mother's Name
Mother's Phone
Father's Name
Father's Phone

Education

Current School
Grade Level
Current (GPA) grade point average

Other Information

Before filling out the remainder of this application, please consider the following information very carefully:

As a Volunteen, I will be a vital part of the hospital staff. I will be expected to act in a professional manner. Considerable effort will be expended to orient and train me in CaroMont Health’s procedures. I commit to work at least 3 months in the Volunteen Program

Date January 18, 2017
Teen Signature (Please type your name acknowledging that you agree)
Parent/Guardian Signature (Please type your name acknowledging that you agree)

NOTE TO PARENTS/GUARDIANS: Attendance is extremely important in the Volunteen Program. Your son/daughter is needed on his/her scheduled day. It is essential that your Volunteen has transportation on the days they are assigned to work. "I have consulted with my son/daughter and will be able to provide them with transportation to and from the hospital on their assigned days."

Date: January 18, 2017
Parent/Guardian Signature (Please type your name acknowledging that you agree)

Volunteer Information

Why are you interested in working as a Volunteen for CaroMont Health?
How did you hear about the Volunteen Program?
List any volunteer work experience
List any work experience
List any hobbies/school activities/sports, etc

Pledge of Confidentiality

As a volunteer at Gaston Memorial Hospital and/or CaroMont Health, I am willing to respect each patient's right to complete confidentiality with regard to his/her hospitalization and any facts regarding the reasons for or type of treatment being received. I agree to abide by the motto of Gaston Memorial Hospital Auxiliary, "What I hear and see here, I leave here."

Date January 18, 2017
Signature (Please type your name acknowledging that you agree)

We make placements without regard to race, color, age, sex, religion or national origin. We strive to place individuals with physical disabilities.