January 1, 2013 Dear Prospective Student Volunteer: Thank you for your interest in becoming a volunteer at Texas Health

Presbyterian Hospital of Dallas. Volunteers are important members of our health care team and provide valuable services to Patients, their families, and our employees. This year, our student volunteer orientation will be held on Thursday, June 13th from 1pm-5pm. All volunteer jobs will start the week of June 17th-21st. Orientation is mandatory and no exceptions will be made. There are a variety of ways you can share your time and talents with those in need. Whether you prefer direct patient contact or behind the scenes work, we will place you in a volunteer position where we will think you will find a good fit. Volunteer opportunities are only available Monday-Friday between the hours of 9a.m. to 5p.m and assignment to any particular unit is not guaranteed. All students are required to give a minimum of 32 hours and must complete 6 weeks of volunteer service. Students 16 years of age and older who successfully complete the summer program and wish to continue during the school year are invited to do so. Please return the enclosed application and 2 reference forms by March 1, 2013. All materials must be returned together either to the volunteer office located on the 1st floor of the main building or mailed to: Texas Health Presbyterian Dallas Attn: Volunteer Services 8200 Walnut Hill Lane Dallas, TX 75231 At least one reference form should be completed by a teacher or instructor. The second reference can be another teacher or adult who has known you for at least two years. Your references may not be relatives. Please return all of this as one complete package of information. All forms must be received by the March 1st deadline for you to be considered for the program. No late applications will be accepted and incomplete application packets will not be considered. Volunteers new to the summer program will be required to participate in an interview during the weeks of March 11-29. Students will be notified by April 26th if they have been selected for the program. All selected volunteers will be required to complete employee health tb screening before attending orientation on Thursday, June 13th. Again, we appreciate your interest and look forward to meeting you soon. Please dont hesitate to call me at 214.348.7580 if you have any questions.

Sincerely, Lauren Wideman Coordinator, Volunteer Services Texas Health Presbyterian Dallas 214-345-7580 LaurenWideman@TexasHealth.org

Texas Health Presbyterian Dallas Volunteer Services 2013 Summer Student Program Application Checklist
Application Checklist Complete all sections of the application and essay If you are over 16, complete the background check release form Enclose 2 reference letters in sealed envelopes with the references signature across the flap Enclose a recent, color 4x6 Photo

This is a 4x6 box. Please make sure your photo is the same size as this box.

Return entire packet in one envelope by March 1st either in person at the Volunteer Office on Main building 1st floor or mailed to: Texas Health Dallas Attn: Volunteer Services 8200 Walnut Hill Lane Dallas, TX 75231

Reminders Students must volunteer a minimum of one 4 hour shift Students may work a maximum of 6 4-hour shifts Total required volunteer hours is 32 Total required weeks is 6 weeks Non-patient and patient related volunteer opportunities are available. Assignment for particular area is not guaranteed. All summer volunteers will be required to purchase a uniform (green polo shirt) from the volunteer office for $20. Parking will be available free for students who drive themselves. Deadlines Applications are due by March 1st All new volunteers must participate in an interview between March 11-30th. Only 50 students will be accepted. Candidates selected for the summer program will be notified by mail by April 26th All new volunteers must have a tb test and immunization check before orientation Orientation is mandatory on Thursday, June 13th 1pm-5pm Questions? Call the volunteer office at 214-345-7580

SUMMER STUDENT VOLUNTEER APPLICATION

Please complete all sections below and attach a recent 4x6 photograph. Date: _________________ Name:___________________________ Social Sec. #_______________ Date of Birth ________ Age as of June 12, 2012 (You must be 14 by June 13 to apply) ____________ Address:__________________________________ City/State/Zip: ________________________ Home phone: ______________ Cell phone: _______________ Email: ____________________ Parent Email:__________________________________ School attending & grade: ______________________________________________________ Have you participated in the summer program before? [ ] Yes [ ] No If no, how did you hear about the summer program? [ ] Employee [ ] Friend [ ] School [ ] Other: ____________ Do you have any relatives who work at THD or THR? [ ] Yes Name:___________________________ Relation: _______________ Department: _______________________________ [ ] No Have you ever been convicted of a felony or misdemeanor? [ ] Yes [ ] No In case of emergency notify: ____________________________________________________ Relationship: _______________ Phone: (home)______________ (work/cell) ______________ What clubs or organizations do you belong to?

______________________________ List any leadership roles, honors, or awards

______________________________ What previous volunteer experience have you had?

STUDENT ESSAY Please type and attach a brief essay (no more than one page typed response ) about why you want to volunteer at Texas Health Dallas. Make sure your essay includes answers the following questions. (1) How does volunteering relate to your career goals? (2) What do you hope to gain or learn as a result of volunteering? (3) What skills do you possess that will make you a successful volunteer? STUDENT AVAILABILITY You are required to work a minimum of one shift/week and may work a maximum of 6 shifts/week. REMINDER: We require that you get 32 hours by the end of the summer.
How many shifts a week would you like to work? (circle answer) 1 2 3 4 5 6 If you circled that you would like to work more than one shift, complete the blanks below.

Please schedule me for ___ half day shifts Please schedule me for ___ full day shifts Please check all that you are available to work. We will match you with only the number of shifts that you want to work but the more available times you have, the more potential departments we can place you in. We cannot accommodate weekend placements.
Days
Monday Tuesday Wednesday Thursday Friday

Morning Shift

Afternoon Shift

9:00 AM 1:00 PM 9:00 AM 1:00 PM 9:00 AM 1:00 PM 9:00 AM 1:00 PM 9:00 AM 1:00 PM

1:00 - 5:00 PM 1:00 - 5:00 PM 1:00 - 5:00 PM 1:00 - 5:00 PM 1:00 - 5:00 PM

Summer orientation is Thursday June 13th . Volunteering will start the week of June 17th unless you note a different start date below. Volunteering ends the week of August 19th unless you note a different end date below. My start date (if not June 17th -21st) ____________________ My end date (if not August 19th -23rd) ____________________ Please indicate if you will have any vacation time requests No, I will be available every week between my start and end date Yes, My vacation times ________________________________________
STUDENT VOLUNTEER PREFERENCES
I prefer to work: Patient Contact Area Non-Patient Contact Area

are:

No preference

STUDENT UNIFORM ORDER Students selected for the program will be required to pay $20 for a green student uniform. Select your size: Womens [ ] x-small [ ] small [ ] medium [ ] large [ ] x-large Mens [ ] small [ ] medium [ ] large [ ] x-large [ ] xx-large

STUDENT AGREEMENT I understand that I am authorized solely to perform tasks assigned specifically to me. I understand that I must follow all rules and regulations of Texas Health Presbyterian Dallas. I understand that all information concerning Texas Health Presbyterian Dallas and its patients is strictly confidential and I hereby agree to maintain this confidentiality. I have read and understand the above and agree to comply with all rules and regulations of Texas Health Presbyterian Dallas. I understand failure to comply with such rules and regulations may be cause for my removal from the Summer Student Volunteer Program. I understand Texas Health Presbyterian Dallas may terminate my volunteer services for any reason, or no reason. ----------------------Signature Date

PARENT OR GUARDIAN STATEMENT (FOR STUDENTS 18 YEARS) It is understood and agreed that I shall not bring or cause to be brought any action due to any personal injury or property damage that might result from my son/daughters participation in any aspect of the volunteer program. I agree to accept full responsibility and to hold harmless Texas Health Presbyterian Dallas, its employees, directors, officers, trustees or agents from any and all claims and damages that may arise from son/daughters participation in the volunteer program. ----------------------Signature Date

Date: _________________ You have been chosen to provide a reference for , who has applied to be a student volunteer at Texas Health Presbyterian Dallas. Please answer the following questions, sign, seal in an envelope with your signature across the flap, and return to the student. Thank you for your help. Sincerely, Lauren Wideman, Coordinator Volunteer Services 214.345.7580 1. How long have you known this student and in what capacity? _______________________________________________________________________ _______________________________________________________________________ 2. What qualities does this student possess that will make him/her a good volunteer? ________________________________________________________________________

3.

Would this student be good working with or around patients? ______________________ Why or why not?

4.

Please rate the student in each of the following areas:

Excellent Dependable Trustworthy Punctual Takes Initiative Personal Appearance Follows Instruction Accepts Feedback Compatible w/ Peers Compatible w/ Adults Team Player Maturity Outgoing Good Average Fair Needs Improvement

5. What other information can you give us that will enable us to offer the best volunteer assignment possible?

________
Signature Date

________
Printed Name

Date: _________________ You have been chosen to provide a reference for , who has applied to be a student volunteer at Texas Health Presbyterian Dallas. Please answer the following questions, sign, seal in an envelope with your signature across the flap, and return to the student. Thank you for your help. Sincerely, Lauren Wideman, Coordinator Volunteer Services 214.345.7580 1. How long have you known this student and in what capacity? _______________________________________________________________________ _______________________________________________________________________ 2. What qualities does this student possess that will make him/her a good volunteer? ________________________________________________________________________

3.

Would this student be good working with or around patients? ______________________ Why or why not?

4.

Please rate the student in each of the following areas:

Excellent Dependable Trustworthy Punctual Takes Initiative Personal Appearance Follows Instruction Accepts Feedback Compatible w/ Peers Compatible w/ Adults Team Player Maturity Outgoing Good Average Fair Needs Improvement

5. What other information can you give us that will enable us to offer the best volunteer assignment possible?

________
Signature Date

________
Printed Name

Volunteer Services

APPLICATION DISCLOSURE APPLICANTS OVER 16 ONLY Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a Consumer Report may be made in connection with your Application for Volunteer Service. If you are denied volunteer opportunity, either wholly or partially, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.

I have read the above notice and understand what it means. I hereby authorize the procurement of a Consumer Report for continued purposes in connection with this application for volunteer service placement. Date:____________________ PLEASE PRINT AND SIGN YOUR LEGAL NAME EXACTLY AS IT APPEARS ON YOUR SOCIAL SECURITY CARD Applicant Signature:_________________________ Print Name Legibly:_________________________ Social Security Number: _____________________ Date of Birth:______________________________

In order to complete a full background check, we will need you to complete the following. Please include city, state and county lived in for the last SEVEN YEARS: __________________ CITY __________________ CITY __________________ CITY __________________ CITY __________________ CITY

__________________ COUNTY __________________ COUNTY __________________ COUNTY __________________ COUNTY __________________ COUNTY

________________ ________________ STATE DATES ________________ ________________ STATE DATES ________________ ________________ STATE DATES ________________ ________________ STATE DATES ________________ ________________ STATE DATES

If you have lived in another country during the last 7 years please contact the volunteer services office at 214-345-7580