Junior Volunteer Form Digital

Stamford Health Junior Volunteer Application

Required fields are marked with *

First Name

Last Name

Date:

Home Phone:

Cell Phone:

Street Address

City

State

Zip

Age:

Date of Birth:

Student's E-mail:

Name of School:

Grade:

Guidance Counselor:

Guidance Counselor Phone Number:

Disclaimer

If I am selected as a volunteer, I understand and agree that I have the right to terminate the volunteer relationship at any time and for any reason and Stamford Health have a similar right. The information supplied by me on this volunteer application is true and complete to the best of my knowledge. I understand that the discovery of any misrepresentation or omission of facts in the volunteer application may result in revoking my volunteer status.

The information supplied by me on this volunteer application is true and complete to the best of my knowledge. I understand that the discovery of any misrepresentation or omission of facts in the volunteer application may result in revoking my volunteer status.

My signature below indicates that I understand and agree with all above statements.

Disclaimer1

Student's Signature:

Today's Date

Essay: Minimum of 250 words explaining why you would like to volunteer and what qualities make you an exceptional candidate for the Stamford Health Junior Volunteer Program.

Essay

Please note: If you would like us to include your parent or guardian on your email please indicate

Parent/Guardian Name:

Cell Phone:

E-mail:

Parent/Guardian Name:

Cell Phone:

E-mail:

How did you hear about us?

Please check one or more: Office Support Arts Entertainment Patient Support

Special talent/language skill:

Identify the days and times you're available weekly:* Monday Tuesday Wednesday Thursday Friday

Times Available:

Stamford Health Parent Permission Section

To be completed by parent or legal guardian.

Name of parent /legal guardian:

Primary Phone:

Work Phone:

Physician:

Physician Phone:

Does your son/daughter/minor have any health concerns that you feel we should be aware of?

I grant permission for my son/daughter/minor to be a volunteer at Stamford Health. I verify the age given to be correct. I will accept the judgment of the Manager of Volunteer Services concerning matters relating to my son/daughter/minor as a volunteer.

Disclaimer2

Signature of parent/legal guardian

Date

Consent for Treatment

Child Name

All minors (under the age of 18) must have on file Consent for Treatment Form. This is a preventable measure in case of illness or injury while on duty, and would be used only after reasonable attempts to reach the parent or guardian had been made.

In the event my son, daughter or minor requires medical and/or surgical treatment while volunteering within Stamford Health. I, the undersigned, hereby give my consent for any medical and/or surgical treatment as the attending physician and/or surgeon deems necessary. This includes the use of anesthetics. I have read the foregoing and understand it.

Disclaimer3

Signature of parent/legal guardian

Date

Stamford Health Junior Volunteer Application

Stamford Health Parent Permission Section

Consent for Treatment