March 2015
Attention: High School Students (including homeschool, private high school, parochial students) –
Sophomores, Juniors and Seniors
Dear Junior Volunteer Applicant:
Thank you for your interest in our Junior Volunteer Program at Conroe Regional Medical Center. Our
program starts June 15, 2015 and extends through August 14, 2015, for a total of nine weeks. In order
to receive a certificate of service all junior volunteers must serve a minimum of forty (40) hours. A full
day of orientation will be held on Wednesday, June 10, 2015, and is mandatory for all participants.
Orientation will start at 9:00 a.m. in the CRMC Auditorium. Volunteering will begin Monday, June 15,
2015.
If you wish to be considered, please submit your completed application (pages 1-6) before May 1, 2015.
You may submit your completed application via mail to the Volunteer Office (address below) or fax it to
(936) 539-7528. Please keep this letter and pages 7 - 11 to refer to.
Please feel free to make as many copies of the application needed to give students in the 10 th, 11th,
and 12th grades.
If you have any questions please call the Volunteer Office at 936-539-7433 or Millie Whaley at 936-4474797.
We appreciate your interest and look forward to hearing from you.
Sincerely,
Mille Whaley
Junior Volunteer Director
Conroe Regional Medical Center
Attn: Volunteer Services
504 Medical Center Blvd.
Conroe, Texas 77304
Phone: 936-539-7433
Fax: 936-539-7528
Application for Junior Volunteer Program
Please Print
Name_______________________________________
Last
First
Middle
Gender (circle one): Male or Female
Birthday _________/________/_________
Month
Day
Year
Street address _______________________________________ Phone _________________________
City and Zip ___________________________________________ Cell __________________________
E-mail address _______________________________________ SS# ____________________________
High school _________________________________________ Grade next fall __________________
Father's name _______________________________________ Occupation _____________________
Mother's name ______________________________________ Occupation______________________
In case of emergency, contact: __________________________ Relationship _____________________
Emergency Phone __________________________ Personal Physician _________________________
Community affiliations (Clubs, Associations, Church, Etc.):
Why are you interested in volunteering? ___________________________________________________
Shirt Size (circle one): S M L XL XXL
Special interests, talents or hobbies: _______________________________________________________
List three adult references (other than relatives):
1. ______________________________
School Teacher or Counselor
2. ______________________________
3. ______________________________
___________________________________________________
Address
Phone
___________________________________________________
Address
Phone
___________________________________________________
Address
Phone
Are you willing to have your references evaluate and give their recommendations to Conroe Regional
Medical Center? (Circle one): Yes or No
Signature __________________________________ Date _______________________
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Parental Consent Form
To:
Auxiliary of Conroe Regional Medical Center
504 Medical Center Blvd.
Conroe, TX 77304
My daughter/son _______________________________ (print first and last name) has my consent to
serve as a Junior Volunteer at Conroe Regional Medical Center. She/he has permission to be vaccinated
for TDAP (Tetanus, Diphtheria, Acellular Pertussis) and screened for Tuberculosis via a blood test called
QFT, in the event that they are not able to submit documentation of these by a healthcare provider to
the employee health office before beginning the program.
Students:
Age_______________________
Grade Next Fall______________
School_____________________
The following lists days he/she will be away this summer (not to exceed one week):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________
Signature of Parent
_______________________________
Date
__________________________________
Street Address
_______________________________
Home Phone
__________________________________
City and Zip
_______________________________
Cell Phone
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Auxiliary of Conroe Regional Medical Center Volunteers
Pledge of Service:
____________________________ (print first and last name) accept membership as junior volunteer of
the Auxiliary of Conroe Regional Medical Center. I promise to conduct myself with dignity, courtesy, and
consideration for others at all times. I will be punctual and conscientious in the fulfillment of my duties
and accept supervision graciously. I will consider as confidential all information, which I may hear
concerning a patient, staff member or employee.
I will endeavor to make my work of the highest quality and uphold the rules and ethics of the Auxiliary
of Conroe Regional Medical Center, and hospital regulations to the best of my ability. I pledge to
properly represent the hospital both as I work and in my living, to the end that all may know of the great
services performed at this institution. I understand that my failure to comply with the above standards
will result in my immediate dismissal.
_______________________________________
Signature
___________________________________
Date
3
Purpose of a Hospital Volunteer Program
The hospital staff is looking forward to the Junior Volunteer program at our hospital. We recognize these
juniors as excellent prospects for hospital careers.
The purpose of a hospital is to promote public welfare through development of better patient care for
all the people. The purpose of a hospital volunteer program is to assist the hospital in the development
of this better patient care by providing volunteer services, promoting better understanding between the
hospital and the community. As a member of the Junior Volunteers you share in the teamwork of
contributing to better patient care, which is the ever present goal of our hospital.
The functions of the Junior Volunteer program are to provide volunteer service, to increase the
community's understanding and interest in the hospital, and to stimulate the interest of its members in
health careers. Each junior volunteer serves as a link between patient and hospital and between hospital
and community, and the volunteer services is an outreach of warmth, generosity, and concern that
symbolizes the message: "this is MY hospital." Such a program specifically gives teenagers an
opportunity to observe hospital life behind the scenes. The cheerfulness, enthusiasm and spirit of the
junior volunteer are a most important public relations program.
Junior Volunteer Pledge:
Believing that the hospital has real need of my services as a volunteer worker:
•
•
•
•
•
•
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I will be punctual and conscientious in the fulfillment of my duties and accept supervision
graciously.
I will conduct myself with dignity, courtesy and consideration.
I will consider as confidential all information which I may hear directly or indirectly concerning a
patient, doctor or any member of personnel and will not seek information in regard to a patient.
I will take any problems, criticisms or suggestions to the Volunteer Coordinator.
I will endeavor to make my work of the highest quality.
I will uphold the traditions and standards of the highest quality.
I will uphold the traditions and standards of this hospital and will interpret them to the
community at large.
Signature: ____________________________________
Date: _____________________________
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5
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The Junior Volunteer program is sponsored and supported by the Auxiliary of Conroe Regional Medical
Center. The Auxiliary provides special awards, financial support and assures the continuity and direction
of the Volunteer Coordinator and Auxiliary Director of Junior Volunteers.
Qualifications:
A Junior Volunteer is a high school student, possibly a medical career student, who is interested in
serving the hospital, its patients and the community. She/he maintains a scholastic average of "C" or
better. Parents must submit their approval in writing.
Junior Volunteers must maintain good physical and mental health and have a sincere interest in helping
others.
All applicants must interview with the Auxiliary Director of Junior Volunteers. If accepted, they must
attend an orientation and training meeting before beginning their assigned duty in the hospital. They
will receive their assignments through the Volunteer Services department or the Auxiliary Director of
Junior Volunteers and will provide service for the area they are assigned. Failure to follow your assigned
duties can result in termination from this program
Goals:
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To offer valuable service to the hospital and the community.
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To learn the meaning of service to the hospital patients.
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To provide exposure to hospital atmosphere in deciding upon a career in the health field.
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To acquire knowledge of the health needs of individuals and ways of maintaining health.
Benefits:
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Complimentary lunch with scheduled assignment.
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Career decisions for students interested in healthcare
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Opportunities for new friendships.
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Continuing educational experience.
Uniform:
All junior volunteers will wear a green polo shirt purchased from the Auxiliary and khaki pants with
white tennis shoes.
Please report for duty in clean, pressed uniform, with shoes polished or clean. The uniform should only
be worn when on duty in the hospital.
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Hair length will be above the shoulders and away from the face. If hair is long, tie it up and fasten
securely. Hair should never be loose on the shoulders.
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No accessories, except a white sweater if needed.
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No jewelry other than watches. No earrings except small studs for pierced ears.
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No heavy makeup or bright fingernail polish.
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Personal hygiene should include clean nails and hair, daily bath, deodorant and mouth hygiene.
•
No perfume or cologne. Some patients may be allergic to odors or may be nauseated after
anesthesia.
•
Keep hands dean from germs by washing hands thoroughly before and after caring for each
patient.
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Stand tall and wear a sincere smile. Remember body posture.
•
Stay at home when you are ill, but be sure to call in 936.539.7433 (leave a message if no one is
there to answer the phone).
Rules of Conduct:
The privilege of being a Junior Volunteer carries with it the responsibility of being loyal to the hospital.
You are working in an adult world and therefore are expected to carry adult responsibilities toward the
patients, hospital personnel, other volunteers and the hospital itself. Study these rules carefully.
- Adhere to instructions issued by personnel in charge and adhere to hospital routine.
- Hospital affairs are strictly confidential and must be so regarded by Junior Volunteers. Avoid discussion
with family or friends any information regarding any patient.
- Always get permission from the nursing staff before visiting a hospitalized friend.
- Perform duties in accordance with established methods of the hospital. Assist patients in a manner
conducive to their safety and comfort When in doubt as to any policy or procedure, ask your supervisor.
- Act at all times in a dignified and considerate manner. While at the hospital you are a part of it, and
should be above criticism. Be patient and cheerful.
- Remain inside the hospital while on duty.
- Avoid asking patients why they are in the hospital.
- Do not give your name and phone number to anyone.
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- If you are injured on the job, have someone notify the Volunteer Coordinator and if possible wait for
further instructions.
- A fifteen-minute break is allotted for each shift. Let your supervisor in the area of your assignment
know that you are leaving and when you return for duty. Soft drinks, gum chewing and candy bars may
only be enjoyed in the cafeteria vending area or the volunteer workroom.
- Being a Junior Volunteer does not include medical services or reduction in hospital rates for yourself or
family members. Medical advice should not be sought from staff physicians for yourself or others.
- At all times, your voice should be kept low and audible, showing courtesy and tactfulness at all times.
Remember, you are a host/hostess for the hospital.
- The information desk is not a gathering place. Suggestions if you need something to do: Visit patients,
distribute magazines to waiting areas, and tidy up tables in waiting areas.
- Your friends may not visit you while you are on duty and telephone use is limited to transportation
needs and/or emergencies.
- Junior Volunteers are to leave the hospital immediately after their shift ends.
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2015 Junior Volunteer Vaccine Information
Effective September 1, 2012 Conroe Regional Medical Center has adopted a policy in regard to
Healthcare worker vaccine preventable diseases. This policy is in compliance with the Texas Health &
Safety Code, Article 8, Chapter 224 and it specifies that individuals volunteering at CRMC will be
vaccinated for TDAP (Tetanus, Diphtheria, Acellular Pertussis) prior to volunteering. In addition to this, a
screening for Tuberculosis, a blood test called QFT, will also need to be completed.
As a junior volunteer you will be required to submit proof of the above by submitting documentation of
these by a healthcare provider to the employee health office. In the event that you cannot submit
documentation of these you can be seen in the employee health office and the health nurse will provide
these to you at no cost.
The volunteer office will provide the employee health office with a list of junior volunteers to contact.
An employee health nurse will contact you and schedule a time for you to come in to receive your
vaccine and/TB Screening and or make arrangements to obtain a copy of your vaccine records. You may
also fax your records to the employee health office at (936)539-7506. In the event that you need to
reach an employee health nurse please contact (936) 539-7469.
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Junior Volunteer Program Checklist and Important Dates
Checklist:
_____ Completely and legibly filled out and pages 1- 6 of the application including signatures
_____ Mailed or faxed pages 1-6 to the volunteer office by April 30th (late applications won’t be
considered)
Conroe Regional Medical Center
Attn: Volunteer Services
504 Medical Center Blvd.
Conroe, Texas 77304
or
Fax #: 936-539-7528
_____ Checked with your healthcare provider to obtain copy of TDAP (Tetanus, Diphtheria, Acellular
Pertussis) Vaccine records and had a copy faxed over to 936-539-7506 or the hospital will provide
you one free of charge.
_____ Contacted the employee health office at (936) 539-7469 to make arrangements to receive
vaccine and/TB Screening and/or to confirm they received a copy of your vaccine records.
Important Dates:
Date
April 30, 2015
Scheduled date of: __________
June 10, 2015
June 15, 2015
August 14, 2015
TBD – will send out notice
Event
Completed volunteer application is due (pages 1-6)
Employee Health Appointment to receive TDAP vaccine and T/B
Screening. Call employee health to schedule a day/time.
Half day of orientation (8:00 AM – Noon) in CRMC Auditorium
Junior Volunteer program starts
Junior Volunteer program ends
Award Ceremony at Incredible Pizza