Volunteen Application
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Month
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Name
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First Name
Last Name
Street Address
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City, State, Zip Code
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Phone
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Email
example@example.com
Date of Birth
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Month
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Day
Year
Date
Emergency Contact - Name
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Emergency Contact - Relationship
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Emergency Contact - Phone Number
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Family Physician
Family Physician Address
Name of School
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Grade Level and Graduation Year
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Career Interest
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Limitations related to health
Are you currently employed? If so, where?
Which times work best for you to volunteer?
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After school 3:30 PM-6:00 PM
Weekends 11:00 AM-2:00 PM
Weekends 3:30 PM-6:30 PM
Summer/Holiday Break Availability:
Reference
Please choose your reference from among the following: teacher, minister, principal, employer, neighbor, etc. This person cannot be a family member.
Full Name
Relationship
Company
Phone
Address
Parental Consent
I have read the information flyer and I give my permission for my child to volunteer at Wyandot Memorial Hospital as a VOLUNTEEN. I further understand that he/she will be required to adhere to the dress code as presented in the cover letter of this packet. In addition, I understand that my child immunization record status is required. My child has my permission to receive phone calls and/or text messages from the VOLUNTEEN Coordinators for informational purposes only. (If you do not want your child to receive text messages, please note that under your signature below). If an emergency arises while my child is on duty and reasonable attempts to contact me at the below phone number are unsuccessful, I give consent for the administration of emergency treatment deemed medically necessary.
Child's Name
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Emergency Phone Number
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Parent/Guardian Name
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Parent/Guardian Signature
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Date
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Month
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Volunteen Commitment & Confidentiality Statement
I have read the information flyer and I commit to 5 service hours per month. I agree that I have enough time in my schedule to complete the 3-month commitment. In the event my schedule changes, I will notify WMH as soon as possible. I have also read and understand the VOLUNTEEN dress code.I understand and agree that in the performance of my duties as a VOLUNTEEN of Wyandot Memorial Hospital, I must hold medical information in the strictest confidence. I may have access to, or hear about, medical information concerning someone's admission, medical care received, tests performed, and/or condition of patients who are treated in the hospital. I am aware that this information may not be disclosed and/or talked about with anyone, including family members. I agree to maintain customer service standards in my interactions with patients, families, friends, and staff.I will not take photos or videos while volunteering. I will not discuss my experiences at Wyandot Memorial Hospital on any social network (i.e., Facebook, Twitter, Myspace, Pinterest, Instagram, Flickr, YouTube, TikTok, etc.).I certify that my answers are true and complete to the best of my knowledge.If this application leads to volunteering, I understand that false or misleading information in my application or interview may result in my release.
Signature
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