Lakeland Regional Medical Center Teen Volunteer Program Form – Fill Out and Use This PDF

Thank you for your interest in the Lakeland Regional Medical Center Teen Volunteer Program. Attached are several documents that must be completed and returned to the Volunteer Services office no later than:

Friday, March 30th 2012.

For many students, this may be the first exposure to the field of patient care services. It is our

desire to keep everyone well informed, enthusiastic, and interested in his or her volunteer experience. We’re proud that many of our volunteers continue to participate throughout their

high school years and pursue medical careers upon graduation.

The following are requirements everyone must meet to be accepted into the Teen Volunteer Program:

1.You must be a high school student at least 15 years of age.

2.Complete and notarize the parental consent form and return it with the application form

3.Furnish proof of 2 Measles/Mumps/Rubella (MMR) Vaccinations (available from your Pediatrician or the Health Department).

4.Students it is your responsibility to call and schedule an interview AFTER receiving notification. Interviews will be held in April and you will be notified of the interview dates.

5.Submit a letter of recommendation from a school Guidance Counselor, Teacher and or Administrator. Please use the form attached. It must be in a sealed envelope.

6.Keep the top 4 sheets for your reference and mail the completed application to: Lakeland Regional Medical Center, 1324 Lakeland Hills Blvd, Lakeland, FL 33805

Attention: Volunteer Services

If we may assist you in any way, please feel free to call the Volunteer Services office at 687-1115.

Sincerely,

LRMC Volunteer Services Staff

Welcome to the Lakeland Regional Medical Center

Teen Volunteer Program

As a member of our Teen Volunteer Program, you will find a personal satisfaction in serving the hospital and our patients as you offer your time and talents. You will have the opportunity to acquaint yourself with a variety of health careers. You will learn new skills and enjoy this adventure into the adult world.

Remember, as a Teen Volunteer you agree to the following commitment.

I Will Be:

DEPENDABLE:

I will be on time for duty. If I am unable to report for duty, I will notify the supervisor that I have been assigned to. I will notify my supervisor or the Volunteer Coordinator in advance of vacation or other scheduled absences.

COOPERATIVE:

I will only work the service I am assigned. If I would like to change services, I will discuss this with the Director of Volunteer Services or the Volunteer Coordinator.

RESPONSIBLE:

I will wear my name badge at all times. I will not bring valuables with me.

I will report any accidents or incidents while on duty to my supervisor, the Director of Volunteer Services or the Volunteer Coordinator.

I will only go into parts of the hospital that are assigned to me.

QUIET:

I will walk and talk quietly in the hallways and rooms.

PLEASANT AND COURTEOUS:

I will remember that I am part of the patient care team and thus contribute to the impression others have of LAKELAND REGIONAL MEDICAL CENTER.

WILLING:

I will be a willing Volunteer, remaining flexible to serve where needed.

REMEMBERING:

I will remember that I am a teenager working in the adult world of medical science. As a Teen Volunteer in the hospital, I must observe the same professional ethics as the employees. To the public I appear as a professional. I must act in a professional manner

I WILL NOT:

Sit on a patient’s bed.

Make personal telephone calls or text while on duty. Cell phones will remain off for the duration of your shifts unless on break.

Visit with friends while on duty. Bring guests to work with me.

Use perfume, highly scented powder, cologne or after shave lotion.

Wear conspicuous make-up or excessive jewelry. All visible pierced body jewelry other than earrings (i.e. eyebrow or nose rings) must be removed.

Chew gum, carry snacks with me, or smoke while on duty.

Sit in or ride in wheelchairs.

Play on the elevators.

Accept tips

Be sure to review additional requirements and rules in the Volunteer Handbook you receive during orientation.

MEALS:

You will be given a meal card for your use when on duty. Volunteers are responsible for charges above $6.00.

Do not take your lunch or dinner break during your 4-hour shift. Please arrange to enjoy your meal before or after your shift.

Arrange to take your meal break during a convenient time frame for the service area.

UNIFORM:

Teen Volunteers are required to wear the red uniform shirt and khaki pants when on duty. Predominantly white tennis shoes should be worn. You may not wear shorts, skorts, any pants made of denim fabric. Capri pants will be allowed as long as they are no more than 4 inches above the ankle.

If you report for duty out of uniform, you will be sent home. If you report for duty out of uniform a second time, you will be released from service.

SERVICE HOUR REPORTS:

You will receive a service report and certificate in September with a complete record of your volunteer hours. These reports are based on the information on the sign-in log. If you do not sign-in, you will not be given credit for the hours unless you call us immediately to correct the error.

The Volunteer Coordinator or the Director of Volunteer Services can sign Community Service forms.

DISMISSAL FROM PROGRAM:

At LRMC, our first concern is for our patients. Volunteers who show disregard for Hospital Policies will result in dismissal from service.

PATIENT CONFIDENTIALITY:

Hospital policy and Federal regulations require all patient information to be kept confidential. Volunteers who breach patient confidentiality will be terminated immediately.

VOLUNTEER WORK DURING THE SCHOOL YEAR

Once you have successfully completed a summer in our Teen Volunteer program, you may return on holidays, hurricane assistance or for other special events during the school year to earn additional service hours. You must call the Volunteer Services office or your volunteer supervisor first to see what needs we have for additional volunteers.

You may also return during subsequent summers if you receive a positive evaluation. Please call the Volunteer Services office by April 1st each year to advise us that you will be returning.

State law requires that all health care workers (paid and un-paid) must pass an annual Tuberculosis (TB) screening. Returning Teen Volunteers must arrange to have a TB test in our Employee Health office each spring.

Lakeland Regional Medical Center

Parental Consent

I understand that my child, ___________________________________ (print name of child) who is

under eighteen (18) years of age and unmarried, has applied for membership as a Teen Volunteer at Lakeland Regional Medical Center (LRMC). I am aware that before serving as a Teen Volunteer, the

following documentation or certified proof of laboratory test results must be obtained from the public health department or my child’s physician and provided to the Volunteer Office:

1.Documentation of receipt of two (2) doses of MMR vaccine on or after twelve (12) months of age or laboratory evidence of Rubella (German Measles) and Rubella (Measles) immunity.

2.Documentation of negative Tuberculosis (TB) skin test within the past six (6) months or if TB skin test is positive, documentation of negative chest x-ray within the past twelve (12) months. (If current documentation is not available, TB tests will be administered at no charge by our Employee Health Staff upon acceptance to the program.)

In the event the results of the TB skin test are unavailable, I hereby authorize the administration of a

TB skin test to my child by personnel from LRMC’s Employee Health Services. If the results of said test are positive, I further consent to having a chest x-ray taken of my child by qualified LRMC personnel.

In the event my child is injured or becomes ill while at LRMC, I hereby authorize LRMC and its personnel to provide appropriate medical care or treatment to my child, as they deem necessary or advisable.

I acknowledge that I have read this consent form in its entirety and understand fully its contents and voluntarily execute it realizing what I am doing by signing it. I further acknowledge that all my questions have been answered to my satisfaction and that I have proper legal custody of my child named above.

(This consent form must be signed in the presence of two (2) Employee Health witnesses or a notary public.)

__________________________	_______________________________________________________________
Date	Parent or Legal Guardian’s
______________________________	_______________________________________________________________
Witness	Parent or Legal Guardian’s
______________________________
Witness

State of Florida

County of _____________

The foregoing Teen Volunteer Parental Consent form was acknowledged before me this _____ day of _______ in the year

_____________ ,by (name of parent or guardian) who is known to me or who has produced

(type of identification) and who did not take and oath.

________________________________________________________________________

Name of Person Taking Acknowledgement

________________________________________________________________________

Signature of Person Taking Acknowledgement

________________________________________________________________________

Title or Rank

Lakeland Regional Medical Center

Volunteer Services

RECOMMENDATION FORM: Please return it to the applicant in a sealed envelope or mail or fax it to:

1324 Lakeland Hills Boulevard	Office 863-687-1115
Lakeland, Florida 33805	Fax 863-413-5960

TO THE APPLICANT:

At Lakeland Regional Medical Center, our first concern is for our patients and their families. It is imperative that all who enter service as a volunteer appreciate the importance of respecting the rules and structures that govern us. Adult and Teen volunteers are required to comply with specific regulations to protect the safety and privacy of our patients. We ask for this letter of recommendation from a teacher, counselor, scout leader or other adult who can speak of your character and reliability and give us the confidence necessary to include you in our program.

_____________________________ is applying for the LRMC Teen Volunteer Program.

(Print applicant’s Name)

TO THE EVALUATOR:

In order to assist us in evaluating the applicant above for admission to the Lakeland Regional Medical Center Teen Volunteer Program, we would appreciate your responses to the

following questions. Comments, which may be viewed as other than positive, will not necessarily preclude a student’s admission to the program.

1.Please comment on the character, attitude and emotional maturity of the applicant.

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2.Does this student have the ability to work in an unsupervised situation?

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3.To your knowledge has the student had any disciplinary problems?

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4.Please comment on the strengths that you feel this student possesses.

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5. Please add any additional comments that you feel would be of assistance to the student or Volunteer Services.

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Name (please print):_____________________________________________________________

Signature: ____________________________________________________________________

Position/Title: __________________________________________________________________

Organization/School: ____________________________________________________________

Daytime phone: ________________________________________________________________