Children's Volunteer Services

Applicant Information *Application Date *First Name Middle Name *Last Name *Address *City *State *Zip *Email *Birth Date  (MM/DD/YYYY) *Home Phone Work Phone Cell Phone Race Asian Pacific Islander African American Native American Caucasian Hispanic/Latino Two or More Races Other/Unknown Race

Emergency Contact Information *Name *Relationship *Primary Phone Cell Phone Work Phone

Education/Work Experience Please check all of the following which best describes your work/school experience: College Graduate Full Time Part Time Name of Institution Major/Career Interest Graduation or Anticipated Graduation Date Employed Full Time Part Time Employer Work Phone Position How Long? Unemployed Retired Out of Workforce Retired/Past Employer Position *Other Work Experience (paid or volunteer) (200 Characters) *Please describe your experience working with children (200 Characters) *Why do you want to volunteer at Children's Hospitals and Clinics of Minnesota? (200 Characters) *How did you hear about the Children's Hospitals and Clinics of Minnesota volunteer program? Self Website/Internet Children's Volunteer Children's Employee Children's Patient Volunteer Fair School Advisor Service Learning Other (please specify)

Skills/Interests *Please indicate any specials skills that you have (i.e. musical, face painting) (200 Characters) *Hobbies/Interests (200 Characters) *Do you know ASL or speak any foreign languages? (200 Characters)

Conviction Record A criminal conviction record does not by itself constitute an absolute bar to volunteering. Volunteer Services will examine the nature of the conviction record, subsequent rehabilitation, and the responsibilities of the position sought in making each volunteer placement. Please read this section carefully before answering. *Have you ever been convicted, pleaded guilty or no contest to a crime? No Yes If Yes, complete the following section: Charge Date of Conviction (MM/DD/YYYY) State and County of Conviction Length of Sentence Date of Probation/Parole (MM/DD/YYYY)

Volunteer Availability Volunteer shifts are typically 3 - 4 hours, schedule according to the department need and volunteer availability. Volunteers are asked to make a minmum commitment of one shift per week for 6 months or 60 hours. *Campus (may select more than one): Minneapolis St. Paul West Woodwinds Roseville *Volunteer job(s) you would prefer (please refer to the list of available volunteer opportunities) Children's Library Clerical Support/Data Entry Developmental Rehabilitation Emergency Department Family Resource Center Home Care/Hospice Infant Care Center Inpatient Units Laboratory Outpatient Clinic Playroom Parent WarmLine Patient Safety Research Pharmacy Pre-Surgery Program Sibling Play Area Surgical Support Surgery Family Waiting Room Children's Library Clerical Support/Data Entry Developmental Rehabilitation Emergency Department Family Resource Center Home Care/Hospice Infant Care Center Inpatient Units Laboratory Outpatient Clinic Playroom Parent WarmLine Patient Safety Research Pharmacy Pre-Surgery Program Sibling Play Area Surgical Support Surgery Family Waiting Room Children's Library Clerical Support/Data Entry Developmental Rehabilitation Emergency Department Family Resource Center Home Care/Hospice Infant Care Center Inpatient Units Laboratory Outpatient Clinic Playroom Parent WarmLine Patient Safety Research Pharmacy Pre-Surgery Program Sibling Play Area Surgical Support Surgery Family Waiting Room *Please indicate the day(s) and time(s) you are most available to volunteer (if possible, please specify the times you are available, i.e. 9:00 a.m. - noon, 5:30 - 8:30 p.m.; or you may place an X in the box). Morning Afternoon Evening  Sunday  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday Are there any physical conditions that we should consider prior to you having direct patient interaction/additional comments? (200 Characters)

Health/Immunity Requirements For Volunteers Evidence of immunity is a requirement for providing patient care at Children's Hospitals and Clinics of Minnesota. Please complete the questions below. If no options can be selected for any disease, you must obtain vaccine/serology/mantoux from your primary care provider and document here. *1. TUBERCULOSIS - one of the following is required: Negative Mantoux within the last 12 months Date:  MM/DD/YYYY Negative chest x-ray (follow-up for + Mantoux)