VBMC_HighSchoolStudentApplication

8/11/2019 VBMC_HighSchoolStudentApplication

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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

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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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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VBMC_HighSchoolStudentApplication

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