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Delivering Next Generation Care
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Children's Volunteer Services
Junior Application Form
Thank you for your interest in volunteering with Children's Hospitals and Clinics of Minnesota. You must be between the ages of 14 and 17 to use the Junior Application. To begin the application process, please fill out all sections of this form.
To complete this application, you will need your
Immunization information
as well as names and address of
personal references
.
You will also need a
parent or guardian
available to approve this application on-line.
A valid email address is a requirement to using the On-Line Application process.
Please make sure you type the email correctly
- as it will be used as a communication tool in the application process.
All items with a red star
*
are required fields.
When you have completed the application, please click the Submit Button at the bottom. Shortly after you will receive an email at the address you provide below. This email will include a confirmation code. Your personal reference will need this code when filling out the On-line Volunteer Recommendation Form.
No application will be considered without a completed Volunteer Recommendation Form.
Applicant Information
*
Application Date
*
First Name
Middle Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Email
*
Birth Date
(MM/DD/YYYY)
*
Primary 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
*
Name of School
*
Last Year Completed
7
8
9
10
11
12
*
Career Interest
*
Graduation Year
*
Volunteer/Work Experience
(200 Characters)
*
School, Church or Community Activities
(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)
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
*
I want to volunteer:
Summers Only
School Year Only
Year Round
*
Volunteer job(s) you would prefer (please refer to the list of available volunteer opportunities)
Child Life/Nursing Services
Clerical Support/Data Entry
Clinic Playroom
Child Life Playroom
Sibling Play Area
Pre-Surgery Program
Child Life/Nursing Services
Clerical Support/Data Entry
Clinic Playroom
Child Life Playroom
Sibling Play Area
Pre-Surgery Program
Child Life/Nursing Services
Clerical Support/Data Entry
Clinic Playroom
Child Life Playroom
Sibling Play Area
Pre-Surgery Program
*
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)
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 does 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:
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)
