September 21, 2017 Dear Prospective Teen Volunteer and Parent(s)/Guardian(s): Thank you for your interest in our Teen Volunteer Program at Navicent Health. Teen Volunteer Applications will be available and accepted October 1, 2017 through February 16, 2018. With the popularity of this program, only a limited number of teens will be accepted. Acceptance will be based on a completed and approved application. Volunteers must be 16 years of age on January 31, 2018 and must volunteer for no less than 100 hours of total service. Teen Volunteers who participate in our Teen Volunteer Program will be required to volunteer through July 31, 2018. Enclosed, please find the following documents: • Teen Volunteer Application Form, • Two School Recommendation Forms, • Background Check Form, • Essay Form • Don Faulk Teen Scholarship Policy and Procedure Sheet. A complete application packet includes: • Signed and completed application form(s) listed above • A COPY of your birth certificate or driver’s license verifying your age • School Recommendation forms from TWO school representatives • Background Check form (must be signed by parent/guardian if student is under 18 years of age). • Essay All forms should be completed and returned during one of two required Information Sessions. Information Sessions will be held on February 20 & 22,, 2018. Teens and parents/guardians are required to attend only one Information Session to learn more about the expectations and requirements of the program. Note: Your application will not be processed if the packet does not contain all required forms and is not received at one of the Information Sessions. If all requirements have been met, qualified teens will be contacted by letter. Placement of teen applicants is based on suitable and available positions. Respectfully,
Darrell Palmer Darrell Palmer Public Relations, Navicent Health (478) 633-1353 -1-
APPLICATION NAME: ______________________________
AGE: _______ DOB: ___________
PHONE: __________________
ADDRESS: _____________________________________ CITY: ________________ STATE: _____ ZIP: ____________ EMAIL: __________________________________________________________________________________________ NAME OF SCHOOL: ______________________________________________________________________________ GRADE circle one:
9
10
11
12
ANTICIPATED GRADUATION DATE: ___________
PARENT/GUARDIAN NAME: _______________________________________ PHONE #_______________________ PARENT EMAIL: __________________________________________________________________________________ CONTACT IN CASE OF EMERGENCY: _________________________________________________________________________________________________ (NAME) (RELATIONSHIP) (HOME PHONE) ARE YOU CURRENTLY EMPLOYED? IF YES, LIST WHERE: _____________________________________________ EXTRACURRICULAR ACTIVITIES: __________________________________________________________________ _________________________________________________________________________________________________ Does your school require volunteer hours for school credit? Have you volunteered for Navicent Health before? ___________________________________
YES NO
YES NO. If so, when?
NAME OF FAMILY PHYSICIAN ________________________________________ PHONE ______________________ HEALTH LIMITATIONS ____________________________________________________________________________ • •
Please understand that not all teen volunteer available areas are on The Medical Center campus, i.e. Wellness Center, Rehabilitation Hospital, etc. Will this be an issue to work in another location? YES NO Shirt size (Cost of Volunteer polo is $20 once you receive your badge)____ S ____ M _____ L _____ XL _____ 2XL
Can you commit to one of the mandatory informational sessions? . ____YES ____NO Tuesday, Feb. 20, 2018 OR Thursday, Feb. 22, 2018. Sessions 3:30 p.m. - 5:30 p.m. at The Medical Center room Trice 8. ATTENTION PARENT/GUARDIAN: Your signature below indicates your approval for your child's participation in the teen volunteer program. Your teen must attach a COPY of his/her birth certificate/driver's license verifying their age, and parent/guardian signature is required on Background Check form if teen is under 18 years old. Deadline for completed Teen Volunteer Application is February 22, 2018. I agree to the above stated guidelines. SIGNATURE __________________________________________________ DATE _____________________________ PARENT/GUARDIAN SIGNATURE (if under 18) _______________________________________________________
-2-
SCHOOL RECOMMENDATION FOR TEEN VOLUNTEER PARENTAL CONSENT: I authorize the release of information from my son/daughter’s school records to Public Relations, Navicent Health. PARENT/GUARDIAN SIGNATURE ______________________________________ Date:___________________ Dear Counselor or Teacher: Each student who applies for volunteer work must have at least two recommendations from his or her school. We would appreciate your evaluation and comments as we select candidates who will best benefit from our program, and serve our organization and the recipients of our services. Please return this form to the student for inclusion with his/her application. You may also email to
[email protected] or mail to the following address: The Medical Center, Navicent Health 777 Hemlock Street Public Relations #MSC 153 Macon, Georgia 31201 (478) 633-1353 RECOMMENDATION FOR TEEN VOLUNTEER NAME OF STUDENT ____________________________________________________ GRADE IN SCHOOL _______ ATTENDANCE SCHOLASTIC RECORD DEPENDABILITY COURTESY WILLINGNESS INITIATIVE
EXCELLENT _________ _________ _________ _________ _________ _________
GOOD ________ ________ ________ ________ ________ ________
AVERAGE _______ _______ _______ _______ _______ _______
BELOW AVERAGE ______ ______ ______ ______ ______ ______
ADDITIONAL COMMENTS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ SIGNATURE __________________________________________ TITLE _____________________________________ SCHOOL ______________________________________________DATE _____________________________________
-3-
SCHOOL RECOMMENDATION FOR TEEN VOLUNTEER PARENTAL CONSENT: I authorize the release of information from my son/daughter’s school records to Public Relations, Navicent Health. PARENT/GUARDIAN SIGNATURE ______________________________________ Date:___________________ Dear Counselor or Teacher: Each student who applies for volunteer work must have at least two recommendations from his or her school. We would appreciate your evaluation and comments as we select candidates who will best benefit from our program, and serve our organization and the recipients of our services. Please return this form to the student for inclusion with his/her application. You may also email to
[email protected] or mail to the following address: The Medical Center, Navicent Health 777 Hemlock Street Public Relations #MSC 153 Macon, Georgia 31201 (478) 633-1353 RECOMMENDATION FOR TEEN VOLUNTEER NAME OF STUDENT ____________________________________________________ GRADE IN SCHOOL _______ ATTENDANCE SCHOLASTIC RECORD DEPENDABILITY COURTESY WILLINGNESS INITIATIVE
EXCELLENT _________ _________ _________ _________ _________ _________
GOOD ________ ________ ________ ________ ________ ________
AVERAGE _______ _______ _______ _______ _______ _______
BELOW AVERAGE ______ ______ ______ ______ ______ ______
ADDITIONAL COMMENTS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ SIGNATURE __________________________________________ TITLE _____________________________________ SCHOOL ______________________________________________DATE _____________________________________
-4-
THE MEDICAL CENTER, NAVICENT HEALTH APPLICANT AUTHORIZATION AND CONSENT FOR RELEASE AND DISCLOSURE We truly welcome your application for the Observer Program with he Medical Center Navicent Health. We are proud of our success and recognize it as the result of the quality and caliber of the employees in our organization. In pursuit of that excellence, we require as a condition of employment and/or continued employment that all applicants consent to and authorize a pre-employment verification of the background information submitted on their application and résumés. This release and authorization acknowledges that this company and MBI, a consumer reporting agency, may now, or at any time while you are employed, administer testing instruments, conduct and retrieve a verification of your education, previous employment/work history, credit record, contact personal references, require that you provide a urine/breath/blood specimen to be tested for the presence of drugs or alcohol, access motor vehicle records, worker’s compensation records and to receive any criminal history record pertaining to you which may be in the files of any federal, state, county or local criminal justice agency in any State and/or other information deemed necessary to fulfill the job requirements. The information received may include, but may not be limited to, the aforementioned agencies. The results of this verification process will be used to determine employment eligibility. Convictions for a felony or misdemeanor will not necessarily be a bar to employment. I authorize MBI Worldwide South of Herrin, Illinois (referred to as "MBI") and any of its agents/designated representatives to disclose orally, electronically, and in writing the results of this verification process and/or interview to the designated authorized representatives of this Company. I do hereby forever release and discharge the Company, its agents, MBI, and its associates to the full extent permitted by the law from damages, losses, liabilities, costs and expenses, or any other charge of complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if adverse action is taken based on information obtained by the Company and to receive orally, written or electronically a copy of the consumer report and a description of the rights of a consumer. I agree that any copy of this document is as valid as the original. I hereby certify that all of the statements and answers set forth on the application form and/or my résumé are true and complete to the best of my knowledge. I understand that if subsequent to employment any such statements and/or answers are found false or that information has been omitted, such false information or omissions will be considered as cause for possible dismissal. NOTE: The following information is provided voluntarily and IS NOT considered as part of your application for employment. It is used for identification purposes in verifying information for employment background verification. Please print clearly all information requested for the past seven years. Applicant’s Name: ____________________________________________________________________________________________ Social Security #: _____________________________________________ Sex: _______ Race: __________ DOB: ________________ Current Address: __________________________________________________________ Yrs: _____ Months: __________________ City: ___________________________________________County________________________ State: ______ Zip: _______________ RESIDENT ADDRESSES FOR STATES OTHER THAN CURRENT STATE DURING PAST 7 YEARS Previous address: _____________________________________________________________ Yrs: ______ Months: ______________ City: ___________________________________________ County: ______________________ State: _______ Zip: ______________ Previous address: _____________________________________________________________ Yrs: _______ Months: ______________ City____________________________________________ County: ______________________ State: _______ Zip: ______________ Drivers license #: _____________________________________________________: State: __________________________________ Teem Volunteer signature: ________________________________________________________ Date: ________________________ Parent/guardian signature (if under 18) _______________________________________________ Date : _______________________ MBI Worldwide 888-896-5735 FAX
-5-
ESSAY Within the space provided below, please answer the following questions in essay form. Please type or write legibly - neatness counts! Do not add any additional sheets or write on the back of this sheet. 1. Tell us why you chose to volunteer at Navicent Health? 2. Share with us what you can bring to the Navicent Health Teen Program by volunteering and why you would be a good volunteer candidate.
___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
-6-
Policies and Procedures for The Medical Center, Navicent Health Don Faulk Teen Volunteer Scholarship The Medical Center, Navicent Health (MCNH) is proud to offer scholarships to three graduating Seniors who are in good standing and have been actively involved in the MCNH Teen Volunteer program. MCNH will award three scholarships: one $1000 scholarship and two $500 scholarships. Scholarships will be awarded at the end of the program year (July) based on the amount of accumulated hours, recommendations from volunteer department supervisor(s), consistency in volunteer hours in the program, and student must be in good standing throughout the duration of the program. Through the MCNH Teen Volunteer program, a teen may start serving volunteer hours as a Sophomore and continue until the end of his/her Senior year. The three seniors with the greatest number of cumulative hours of service will be awarded the scholarships. A candidate for the Teen Volunteer Scholarship will have a head start on being awarded the scholarship by starting early in their high school years as a MCNH Teen Volunteer. The Medical Center, Navicent Health Auxiliary will disburse scholarship funds (one $1000 scholarship and two $500 scholarships) to the institution directly indicated by the recipients. The decision of the Scholarship Fund Committee is final. A one-time check will be issued to the institution of the student’s choice; this is not a renewable scholarship. The money will be sent directly to the education institution on behalf of the recipient and is to be used for tuition, books, meal plan, and dormitory cost. Please present the Auxiliary with an invoice from your financial institution. Please provide an address and a Student ID number so the monies can be credited to the correct account. These scholarships do not cover off-campus housing. Any unused money will be refunded to the MCNH Auxiliary. If you have any questions please contact the scholarship chairperson, Bea Brooks at (478) 628-2411. -7-
