Mon Health System

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JUNIOR VOLUNTEER APPLICATION

Name:
Address:
City:
State:
Zip:
Daytime Phone:
E-mail Address:
Birthdate:
SS No.:


PARENT OR GUARDIAN:
Name:
Relationship:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:


EMERGENCY CONTACT:
Name:
Relationship:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:


SCHOOL:
School:
Grade:
Extraccurricular Activities (school, church, community):


1. Career interests:

2. Limitations related to health:


3. Have you ever been convicted of a crime? Yes No
If yes, explain when, where and disposition of the case.

4. Is volunteer work a requirement for school credit? If so, number of hours required:



AVAILABILITY (please check all that apply and list times where applicable):
	MON	TUES	WED	THUR	FRI	SAT	SUN
Morning
Afternoon
Evening



REQUIREMENTS: Completion of eighth grade. Copy of immunization records. Initial commitment of 50 hours. Three (3) letters of recommendation. Parents signed approval.

REFERENCES:
1. Please mail three (3) written references from teachers, minister, friends, or neighbors for whom you babysat. References from relatives are not acceptable. Applications will not be considered unless three (3) reference statements are mailed to the address listed below. 2. Please mail a copy of your immunization record with your application.


Mail references, immunization record and parental consent to: DIRECTOR OF VOLUNTEER SERVICES Monongalia General Hospital 1200 JD Anderson Drive Morgantown WV 26505 Further information may be obtained by calling the Volunteer Office at (304) 598-1324.

APPLICANT SIGNATURE: . DATE: 07/25/2008 · 07:55PM

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