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) Chaplaincy Child Life Playroom Clerical Support/Data Entry Developmental Rehabilitation Emergency Department Epilepsy Unit Family Resource Center Home Care/Hospice Inpatient Units Library Cart/Wagon Pharmacy Pre-Surgery Program Sibling Play Area Surgery Family Waiting Room Welcome Desk Greeter/Guide Chaplaincy Child Life Playroom Clerical Support/Data Entry Developmental Rehabilitation Epilepsy Unit Emergency Department Family Resource Center Home Care/Hospice Inpatient Units Library Cart/Wagon Pharmacy Pre-Surgery Program Sibling Play Area Surgery Family Waiting Room Welcome Desk Greeter/Guide Chaplaincy Child Life Playroom Clerical Support/Data Entry Developmental Rehabilitation Epilepsy Unit Emergency Department Family Resource Center Home Care/Hospice Inpatient Units Library Cart/Wagon Pharmacy Pre-Surgery Program Sibling Play Area Surgery Family Waiting Room Welcome Desk Greeter/Guide *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.). 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) Date:  MM/DD/YYYY Treatment for active disease Date:  MM/DD/YYYY *2. Immunity to CHICKENPOX (varicella) defined as one of the following: History of chickenpox infection or shingles Lived in same household as someone with active chickenpox Positive serology indicating immunity to chickenpox Date:  MM/DD/YYYY If vaccinated prior to age 13 - ONE dose of varicella vaccine Date:  MM/DD/YYYY If vaccinated when 13 years or older; Two doses of chicken pox vaccine Date:  MM/DD/YYYY Date:  MM/DD/YYYY *3. Immunity to MEASLES (rubeola) defined as one of the following: Positive serology (antibody test) indicating immunity to measles Date:  MM/DD/YYYY Date of birth before 1/1/1957 Reliable History of Measles One dose of vaccine (MMR, MR, or Measles) Date:  MM/DD/YYYY Date of birth 1/1/1957 or later MD diagnosis of measles Two doses of vaccine (MMR, MR, Measles) Date:  MM/DD/YYYY Date:  MM/DD/YYYY *4. Immunity to RUBELLA defined as one of the following: Date of birth before 1/1/1957 Positive serology (anitbody test) indicating immunity to rubella Date:  MM/DD/YYYY One dose of vaccine (MMR, MR, rubella) Date:  MM/DD/YYYY *5. Immunity to MUMPS defined as one of the following: Date of birth before 1/1/1957 MD diagnosis of mumps Positive serology (antibody test) indicating immunity to mumps Date:  MM/DD/YYYY At least one dose of vaccine (MMR, or mumps) Date:  MM/DD/YYYY Immunity status unknown (note:immunity recommended, not required) *6. Immunity to HEPATITIS B defined as one of the following: Completion of vaccine series Date:  MM/DD/YYYY Positive serology (antibody test) indicating immunity to hepatitis B Date:  MM/DD/YYYY Immunity status unknown (note: immunity recommended) I understand that Hepatitis B vaccine is strongly recommended for health care workers, but decline vaccination. *Physician's Name   *Phone

Personal/Professional Reference IMPORTANT:  Once your application is submitted to Children's Hospitals and Clinics of Minnesota, you will receive an email (at the address provided above) with instructions for completing the On-Line Volunteer Recommendation form. This On-Line Volunteer Recommendation form CANNOT be completed by a relative. Your application will not be considered until a recommendation form is submitted via our website.

Thank you for taking the time to complete this application and to provide all the information that is requested. By checking this box, you are indicating that the information in this application is accurate and correct to the best of your knowledge. You are also indicating your approval for us to verify references and to contact your doctor regarding your physical/emotional health. Children's Hospitals and Clinics of Minnesota Volunteer Services department is not obligated to provide placement, nor are you obligated to accept the position offered. Children's Hospitals and Clinics of Minnesota is an equal opportunity employer and is committed to a diverse workforce.