Post on 02-Jun-2018
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Sara Forman Hart Volunteer SuiteVassar Brothers Medical Center45 Reade PlacePoughkeepsie, New York 12601
Picture Yourself a VBMC Volunteer !
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Dear Student,
What does your future hold? The answer to this question is entirely up to you. Everything that
you do from this point on is a stepping stone to the person you will become. There is a world ofopportunity just waiting for you!
As you make the decisions that will shape your life, Vassar Brothers Medical Center is here tohelp you. Volunteering at VBMC will:
provide valuable experience that will help you to get into the college of your choice; give you exposure to the vast career opportunities in the exciting field of health care; be a fun, rewarding experience and an opportunity to meet new friends.
How to Apply:
Fill out the attached application form Have the enclosed medical information forms completed by your physician Be sure to get all required signatures:
o Parental consento Guidance Counselor recommendationo Physicians signature
Mail to: Sara Forman Hart Volunteer SuiteVassar Brothers Medical Center
45 Reade Place
Poughkeepsie, New York 12601
Once we receive your application:
An appointment will be made for you to meet with our Employee Health Nurse You will be interviewed by the Volunteer Supervisor If accepted into the program, you will be notified about orientation date
We requir e that all VBM C Student Volunteers: Complete a minimum of 50 hours of service Wear the required VBMC Student Volunteer uniform and name badge at all times during
service hours (order form enclosed) Abide by the policies and procedures of the VBMC Volunteer Department
Summer Volunteer Patient Care Assistant Program
We encourage those who are already considering a career in health care to join our Volunteer
Patient Care Assistant Program. This program, which requires an additional 8 hours oftraining, will enable you to work alongside the patient-care staff helping to meet the needs of our
patients. You will become a valuable member of our health care team, and know the satisfaction
that can only come from making another person happy. To be a member of this elite team youwill need to:
Attend an 8-hour mandatory training program Commit to an average of 8 hours of service each week during your summer vacation
We look forward to meeting you! Please feel free to call us with any questions.
Tara Marquis
Manager, Volunteer Resources
845-431-5664tmarquis@health-quest.org
mailto:tmarquis@health-quest.orgmailto:tmarquis@health-quest.orgmailto:tmarquis@health-quest.orgmailto:tmarquis@health-quest.org8/11/2019 VBMC_HighSchoolStudentApplication
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Dear Parent/Guardian:
Thank you for allowing your child to participate in the Student Volunteer Programat Vassar Brothers Medical Center. We are sure that the experience will be notonly beneficial to them, but enjoyable as well.
The New York State Department of Health requires that all employees andvolunteers be given physicals and prove immunity to certain diseases. Please askyour childs health care provider to:
Complete the enclosed health history form
Provide your childs immunization record Provide signature where indicated
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Consent for Necessary Medical Procedures
I hereby give permission to physicians and/or medical staff of Vassar Brothers Medical Center to
render procedures (blood tests, skin test and/or chest x-ray) deemed necessary for the proper
testing of hospital employees and volunteers as required by New York State Department ofHealth regulations.
PPD (Tuberculin) skin testing (or chest x-ray, if applicable) Rubella (German Measles) blood test Rubeola (Measles) blood test Varicella (Chicken Pox) blood test
Parent/Guardian consent: ______________________________________________________
Volunteer Signature:___________________________________________________________
Date:_______________________________________________________________________
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Dear Doctor:
__________________________________________________ has applied for a Volunteer assignment at Vassar BrothersHospital and has listed you as their health provider. This volunteer may be assigned to work directly with patients,therefore as part of the application process, it is important for us to evaluate the individuals health status. Would youplease complete the brief form below and return it to the applicant. Thank you for your input.
Allison Tebolt, Nurse PractionerEmployee Health Services
I, ____________________________________________ give permission for release of the requested
information.
___________________________________________ _______________________________Applicant or guardians signature Date
Has the applicant any physical or mental disability about which we should be aware before making our assignment? Orthat might prohibit him/her from volunteering in the hospital? No____ Yes ______ If yes, please explain on reverseside of form.
Physician Signature _________________________________ Date: ___________________
Please complete below, if known
PPD (Mantoux Tuberculin Skin Test).Date:____________________ Results: __________
Two (2) RubeolaVaccinesor 2MMRvaccines since first birthday if born after 1/1/57.
Date: _________________ Date: __________________ DOB: _______________________
orRubeola Titre Date __________________________ Results: _______________
RubellaTitredate: _____________ Results: ____________ All volunteers regardless of age must showimmunity to Rubella (Will be done in Employee Health if results not available).
Hepatitis B Vaccine :#1 _____________________(dates)
#2 _____________________
#3 _____________________
Tetanus Date : __________________
VaricellaHistory _________
Varicella TitrePositive Date: _____ _______
Varivax#1__________________________
#2 _________________________
VB 50291 Rev. 10/07
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HEALTH HISTORY
NAME: MALE
FEMALE
Date of Birth Age
HOME ADDRESS CITY
STATE
ZIP
HOME TELEPHONE Notify in Case of Emergency:
Relationship: Telephone:DEPARTMENT POSITION SHIFT
HEALTH HISTORYIn order to assist the healthcare provider to determine your ability to perform the essential functions of the job or the need for reasonableaccommodations, please complete the following about your health history:
Have you had any of the following? CheckYes( ) or NO ( ). If Yes, indicate year(s)of occurrence
YES NO YEAR Have you had any of the following?
Check Yes or NO. If Yes, indicate
year(s) of occurrence
YES NO YEAR
Any skin or other health-related conditionwhich causes irritated skin or open lesions
Stomach Disorder (ulcer, GERD)
Mouth or Dental Problems Bowel or Rectal Disorder (frequentdiarrhea, chronic constipation)
Hearing loss or problems Kidney or Bladder Disease
Vision problems (color blindness, cataract,glaucoma, other)
Diabetes
Severe Headaches Thyroid Disease
Difficulty breathing (asthma, chronicbronchitis, emphysema, shortness of breath,chronic cough)
Tuberculosis
Neurological Disorder
Heart Condition, murmur, heart attack,Rheumatic Fever
Seizure disorder (epilepsy or other)
High Blood Pressure Hernia
Anemia, blood disorder Hepatitis or Liver disease
Cancer Mental Illness or breakdown
Have you been hospitalized in last 2 years Have you been treated for substance abuseor addiction
Have you had an injury, recurring pain, limited motion or surgery associated with:
Neck Back
Shoulder Knee/Ankle
Arm/Wrist/Hand Other
Do you smoke now? NO YES
If yes, how much?________ If you stopped smokingcompletely, how many years ago? _______
Do you drink alcohol? Yes No
If yes, how many drinks per week ______per month? ______
Rarely ________
Have you had any surgeries, or any other health conditions, please list:
__________________________________________________________________________________________
__________________________________________________________________________________________Comments:
ALLERGIES:
2. List all medicationallergies and type of reaction:______________________________________________________________________________________________________
Do you have other allergies, please list:______________________________________________________________________
Are you allergic or sensitive to LATEX (natural rubber): YES NO
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Has your Mother, Father,
Sister, or Brother had a history
of:
Yes No relationshipName of personal
physician/provider:______________________________
Address:
Tuberculosis
Diabetes Females:Last Menstrual Period: ________
Last Gyn Exam :_______________
Are you pregnant YesNo
Males:
Last testicular
exam:________
Last prostate exam:________
High Blood Pressure
Heart Disease
Mental Illness
Cancer
Comments:_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
MEDICATIONS
4. Do you take any medications on a regular basis? Yes No If yes, please list: ________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
5. Do you have any other medical condition(s) we should know about in case of a medical emergency? Yes No If yes, please describe:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
HISTORY IMMUNIZATIONS/COMMUNICABLE DISEASE
6. Please check () and list date(s) for the following communicable diseases and/or immunizations and TB skin tests:And please submit any available documentation.
TYPE Yes No Vaccine DATES
Tuberculin Skin Test:
Last date: __________ negative positive
Last Chest x-ray __________________
(Applicants with a positive history must complete
an additional questionnaire)
Chicken Pox
Rubella (German Measles)
Measles
Mumps
Hepatitis B
Tetanus
All employees are required to have Tetanus Diphtheria Vaccine unlessimmunized within the past 10 years.
I certify that the above information is correct to the best of my knowledge and recollection, and I hereby authorize Vassar Brothers
Medical Center to investigate all statements given herein. If found false, I agree that this will constitute sufficient grounds for
termination of employment. In addition, I also give my permission for a medical examination as required by VBMC, and for
immunizations and laboratory testing required by the New York State Health Code and Hospital Policy for Hospital Employees. This
and other medical information will be held in strict confidence. It will be released only where required by law. Non-confidential
information regarding work restricitions relating to job assignment will be provided to management and personnel.
Signature of Applicant: _______________________________________________Date:_____________________
Reviewed by Health Provider (Signature):________________________________________________________________________ H&P: Vol 4-03
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Sara Forman Hart Volunteer Suite 45 Reade Place Poughkeepsie NY 12601 845-431-5664
STUDENT VOLUNTEER APPLICATION FORMPERSONAL
Last Name First
Middle
Date of Birth
Street Address Apt. No. Telephone Number
Home: ( )
Cell: ( )
E-Mail Address:
City State Zip Code
Parent/Guardian Name: Daytime Phone: Evening Phone:
Emergency Contact (If Different From Above): Relationship:
EDUCATION INFORMATIONSchool What Year Will You Graduate?
Address Telephone
Guidance Counselor
Educational Goals:
YOUR INTEREST:
Patient Care Outpatient Registration Guest Services/Information Desk Gift Shop
Clerical Assignments Flower Delivery Patient Transportation Fishkill Amb/Surg Center
Food & Nutrition Cancer Center Same Day Surgery Graphic Arts
Library Cart
AVAILABILITY:
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
8:3012:30MORNING
12:304:30AFTERNOON
4:307:00EVENING
APPLICABLE SKILLS/TALENTS/INTERESTS:
Fluency in another language , including sign language (Please specify):________________________________
Photography Art (ie: painting/crafts) Other (Please specify):________________________________
STATEMENT OF APPLICATIONThe above statements are true and all information and reference given on this application may be investigated without liability of
Vassar Brothers Medical Center. If accepted to participate in the Program, I agree to abide by the policies of the Volunteer
Department of Vassar Brothers Medical Center. I understand that if any of the statements in this application are found to be untrue,
or I fail to comply with all stated requirements, I may be subject to immediate dismissal from the Vassar Brothers Medical Center
Volunteer Program.
SIGNATURE: ____________________________________________________________
****Please complete information on reverse side!****
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