Teen Volunteer Application
Teen Volunteer Application 1/2019
Dear Teen Volunteer Applicant,
Thank you for your interest in volunteering at The Valley Health System. You have chosen to be part of a dynamic team
of volunteers who enhance the patient experience at our facilities. Please carefully review and complete all sections of
the application. Teenagers who are interested in volunteering must meet the following requirements:
Must be 16 - 18 years old and enrolled in high school
Have a grade point average of 2.5 or higher
Be able to perform tasks independently with minimal supervision
Meet minimum health requirements
Communicate well in English
Be willing to purchase volunteer shirt
In an effort to ensure the application review process is timely, please review the list of items needed to complete your
application. All parts of the application must be turned in as one completed packet. Please also note that incomplete
applications will not be processed. We suggest making a copy of your application for your records prior to submitting.
Teen Volunteer Applicants (ages 16-18)
_____ Application
_____ Parental Consent Form
_____ Consent to Release School Records
_____ School Guidance Counselor/Teacher Evaluation
Upon receipt and consideration of your completed application, you will be contacted for an interview to discuss the
exciting volunteer opportunities at one of The Valley Health System hospitals. We ask for a minimum commitment of
hours annually; this commitment requirement varies by hospital.
Every new volunteer is required to attend New Volunteer Orientation, an educational session covering such topics as
safety, infection prevention and patient confidentiality. Volunteers are also required to have an initial and annual
tuberculin skin test. If you have any questions about the volunteer application process, please feel free to contact the
Office of Volunteer Services at your hospital of interest.
Thank you for your interest in volunteering.
At which hospital(s) are you interested in volunteering?
Centennial Hills Hospital
Contact: Tara Babcock
6900 N Durango Drive
Las Vegas NV 89143
Ph:702-835-9860
Fax:702-629-1650
Email:tara.babcock@uhsinc.com
www.centennialhillshospital.com
Desert Springs Hospital
Contact: Kathleen Shelby
2075 E Flamingo Rd
Las Vegas NV 89119
Ph:702-369-7782
Fax:702-853-8571
Email:[email protected]
www.desertspringshospital.com
Henderson Hospital
Contact: Marlene Hughett
1050 Galleria Drive
Henderson NV 89011
Ph:702-963-7584
Fax:702-963-7555
Email:marlene.hughe[email protected]
www.hendersonhospital.com
Summerlin Hospital
Contact: Regale Harris
657 Town Center Drive
Las Vegas NV 89144
Ph:702-233-7532
Email:Regale.harris@uhsinc.com
www.summerlinhospital.com
Spring Valley Hospital
Contact: Therese Elliott
5400 S Rainbow Blvd
Las Vegas NV 89118
Ph:702-853-3538
Fax:702-853-3057
Email:[email protected]
www.springvalleyhospital.com
Valley Hospital
Contact: Kathleen Shelby
620 Shadow Lane
Las Vegas NV 89106
Ph:702-388-4574
Fax:702-388-4750
www.valleyhospital.net
IF ACCEPTED AS A HOSPITAL VOLUNTEER, I AGREE THAT:
Teen Volunteer Application
Teen Volunteer Application 1/2019
1. I shall hold as absolutely confidential, all information I obtain directly or indirectly concerning patients,
doctors or staff, and not seek to obtain confidential information.
2. My services are donated to the hospital without contemplation of compensation or future
employment, and given with humanitarian, religious or charitable reasons.
3. I shall submit to an annual tuberculin skin test and any other health examination which may be
necessary as part of my volunteer services.
4. As a TEEN VOLUNTEER I am between 16 years and 18 years old and currently attending high school.
5. I understand I am required to take safety and educational training yearly or as required by the hospital.
6. I shall be punctual and conscientious, conduct myself with dignity, courtesy and with consideration of
others, in my endeavors as a professional volunteer.
7. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that
I accept.
8. I shall at all times uphold the mission, vision, values and standards of the hospital.
9. I understand the Volunteer Services Department reserves the right to terminate my volunteer status as
a result of (a) failure to comply with hospital policies, rules and regulations; (b) absences without prior
notification; (c) unsatisfactory behavior or conduct, work appearance; or (d) any other circumstances
which, in the judgment of the department director, would make my continued services as a volunteer,
contrary to the best interests of the hospital.
I have read each of the above conditions and I agree to be bound by them as well as all hospital policies and
procedures with The Valley Health System.
______________________________ _________ ________________________ __________
Applicant Signature Date Parent Signature Date
Office of Volunteer Services - Parental Consent Form
Teen Volunteer Application
Teen Volunteer Application 1/2019
This consent form assures that you understand and agree to the following:
1. Your child meets the age requirement of 16 -18 years of age and enrolled in high school.
2. He/she volunteers with your approval.
3. Both you and child realize that volunteering at a hospital within The Valley Health System is a very
important commitment.
4. Your child must follow all rules and regulations established by the Office of Volunteer Services and The
Valley Health System, especially as it relates to attendance at volunteer orientation and maintaining patient
confidentiality at all times.
5. I understand my child will have a two-step tuberculin skin test prior to volunteering and that The Valley
Health System will administer this test at no cost to me. I further understand my child must have a
tuberculin skin test annually in order to continue volunteering.
6. Your child must be regular in attendance and in the proper uniform.
7. Your child commits to volunteering the minimum number of volunteer hours specified by the hospital
where volunteer service will be completed.
It is the policy of The Valley Health System that any minor volunteering should have a parent’s consent for any
emergency treatment needed while volunteering.
I hereby give permission for my child to perform volunteer services at The Valley Health System.
I realize the need for my child to be dependable, courteous and uphold the hospital code of ethics. I will be glad to
cooperate with him/her in complying with the rules and regulations set up for both the volunteer’s and hospital’s
protection.
I will not hold The Valley Health System or its hospitals responsible for any illness or injury incurred by my
son/daughter, which is related to a previously existing medical condition/disability.
I understand it is my responsibility to inform the Office of Volunteer Services of any such pre-existing
condition/disability prior to my child’s receiving his/her assignment.
I give permission to the provided references to release information on my child as requested on the reference form
by the Office of Volunteer Services at The Valley Health System.
I authorize a representative of the my child’s school to complete the School Guidance Counselor/Teacher
Evaluation Form in connection with my child’s application to participate in the Teen Volunteer Program at The
Valley Health System. I understand the purpose of the form is to aid The Valley Health System in selecting qualified
Teen Volunteers.
It is my understanding that all information will be kept in strict confidence.
Printed Name (parent/guardian): _____________________________________________________________
Signature (parent/guardian):_________________________________________ Date: __________________
Teen Volunteer Application
Teen Volunteer Application 1/2019
Student Counselor/Teacher Evaluation Form
The student named below is applying for membership in the Teen Volunteer program at The Valley Health System. The
following information is requested to assist in evaluating the applicant’s eligibility.
Please return form to the student.
Dear Counselor/Teacher:
As Parent/Guardian I hereby give my permission for the release of this requested information.
Parent/Guardian Signature:_____________________________________________ Date:_________________
Student’s Name:_______________________________ School:_______________________________
In recommending this student for volunteer service, please take into account that every volunteer assignment in a
hospital setting is a serious assignment. The Teen Volunteer must be able to adjust to working in an environment where
patients and their families are experiences varying levels of stress. As the volunteer moves about the hospital, he/she
must be able to conduct himself/herself in a mature manner, with poise and courtesy.
School Attendance Record
Good
School Punctuality Record
Good
School Academic Record
Good
Characteristics
Superior
Good
Average
Poor
Leadership
Ability to follow
directions
Ability to work
independently
Ability to work with
others
Emotional Stability
Appearance
I recommend this student for volunteer services
Yes
No
Comments:
Printed Name: _____________________________________________ Title: ____________________________
Signature: ________________________________________________________ Date: ___________________
Teen Volunteer Application
Teen Volunteer Application 1/2019
Birthdate(MM/DD/YY): ______________
I certify that I meet all criteria The Valley Health System requires in
order to be a teen volunteer and that I am 16-18 years of age, enrolled
in high school.
Applicant Contact Information
Name:____________________________________________________________________________________________________
Last First Middle
Address:__________________________________________________________________________________________________
___
Street City State Zip Code
Home Phone: _____________________
Cell Phone:
_______________________
Email Address: _________________________________________________________
Preferred Method of Contact: Home Phone Cell Phone Email
School Information
Name of School:
_____________________________
Grade: ___________ GPA: _____________ Graduation Year:
____________
Work or Volunteer Experience
Volunteer Experience:
Name of Organization: _________________________________________________________________
Dates of Service:_________________ Position: _____________________________________________
Volunteer Experience:
Name of Organization: _________________________________________________________________
Dates of Services:________________ Position: _____________________________________________
Work Experience:
Name of Employer: ____________________________________________________________________
Dates of Employment: ____________ Position:______________________________________________
Emergency Contact Information
Parent or Guardian’s Name: ___________________________________________________
Home Phone: ______________________
Work Phone: ____________________
Cell Phone: _________________
Teen Volunteer Application
Teen Volunteer Application 1/2019
Personal Interests - Tell Us About Yourself
How did you hear about our Teen Volunteer Program?
Are you interested in a Medical Career? If yes, what area?
In what area(s) are you interested in Volunteering? 1. ______________________________ 2. _________________________
Who encouraged you to volunteer?
Have you previously applied to the Teen Volunteer Program? If yes, when?
Availability – Please indicated below ALL days and times you are available to volunteer
Times
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8 am - 12 pm
12 pm - 4 pm
4 pm - 8 pm
References
1. Name: _______________________________
Relationship: ____________________________
Address:__________________________________
__________________________________
Phone: ___________________________
Email: ___________________________
2. Name: ______________________________
Relationship: ___________________________
Address:__________________________________
__________________________________
Phone: ___________________________
Email: ___________________________
The information provided is accurate and correct to the best of my knowledge. My signature indicates that I give my
approval and permission for The Valley Health System to check my references. I understand I will not be compensated
for my services and I understand that the Office of Volunteer Services is not obligated to provide a placement, nor am I
obligated to accept the position offered. My signature indicates if an assignment is accepted, I agree to abide by all The
Valley Health System rules and regulations as they will be outlined in the New Volunteer Orientation and Volunteer
Handbook.
Applicant Print Name: ______________________________________________
Applicant Signature: ________________________________________________Date ________________
OFFICE
For Office Use Only
Teen Volunteer Application
Teen Volunteer Application 1/2019
Date Application Received: _________________________ Application Complete: YES or NO
Interviewer __________________________________________ Date _____________ Time ________
Orientation Date: _________________ First Day Scheduled: _______________ Supervisor Notified ______
Assignment __________________________________ Day(s) ______________ Time(s) __________
Comments:
_________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________