*Indicates required information. Junior Volunteer Application Personal Information First nameLast nameMiddle initialSuffixStreet addressStreet address 2CityZip CodePhone numberFormat: 000-000-0000E-mail addressSchoolCurrent Grade Person to be notified in case of accident or illness Emergency Contact NameEmergency Contact Phone NumberRelationship to emergency contactFather's NameFather's daytime telephone numberMother's NameMother's daytime telephone number Volunteer Information Previous Volunteer Experience Are you related to anyone at Medina Hospital? Yes No If yes, what department do they work in?Please indicate how long you intend to volunteer 40 Hours Six months or less Six months or more One year or longer Volunteer Service Area Preferred Choice 1Choice 2Choice 3 Availability Volunteers are scheduled one day a week for a four hour shift of either 8 am-12 pm, 12-4 pm or 4-8 pm. Please note any days and shifts you would be available for volunteering. Day of the week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Shift 8 a.m. - 12 p.m. 12 - 4 p.m. 4 - 8 p.m. Who referred you to Medina Hospital to volunteer? Friend/Relative Media/Ads Employee Physician My preferred hospital Other Have you ever been convicted of a felony? Yes No If so, please explain. Have you been convicted of any crime other than a minor traffic violation? Yes No A conviction will not automatically disqualify an applicant. The nature of the crime, the date of the conviction, and other pertinent details may be considered.)If so, please explain. Contact 1 Please list a school guidance counselor and an adult (please do not include relatives) we may contact for a reference: First NameLast NamePhone NumberFormat: 000-000-0000RelationshipCityStateZip CodeStreet Address Contact 2 Please list a school guidance counselor and an adult (please do not include relatives) we may contact for a reference: First NameLast NamePhone NumberFormat: 000-000-0000RelationshipCityStateZip CodeStreet Address Please state your reasons for wanting to become a volunteer at Medina Hospital Please read and provide your digital signature Medina Hospital is not obligated to provide a placement, nor are you obligated to accept the position offered. The Hospital also reserves the right to modify or eliminate the placement at any time for any reason, and you also may leave at any time. The offering of and/or placement in a position does not bestow any rights, privileges or benefits, employment or otherwise, upon you. My signature below affirms all the facts set forth in my application for volunteering are true and complete. I understand that if accepted, false statements, omissions or other misrepresentations by me on this application may result in immediate dismissal. I understand that I will be required to attend the hospital orientation and annual educational programs as required by Medina Hospital. I also understand and agree that in the performance of my duties as a volunteer of Medina Hospital I must hold in strictest confidence any observations I may make or hear regarding clients, client families or staff. I understand that intentional or involuntary violation of confidentiality may result in disciplinary action, including termination of volunteer services and/or possible legal action by others (i.e., clients, families of clients, etc.) Digital SignatureDate