Junior Volunteer Application (For High School & College Students) Requirements: -Applicant must be at least 14 years old by June 1. -Applicant must be available to volunteer at least one 4 hour shift per week (Mon-Fri) from June 15 – August 7 -Applicant must complete and submit application before May 1, 2015 to the Imaging/Volunteer Department in 1 of 3 ways: -Email: -Fax: -USPS: [email protected] 281-348-8349 Kingwood Medical Center Attn: Imaging/Volunteer Dept. 22999 US Hwy 59 North Kingwood, TX 77339 Pre-selection: -Upon review of applications, candidates will be contacted via email to schedule an interview. -After pre-selections are complete, top applicants will receive emails indicating they’ve been selected to become Junior Volunteers. Post-selection: -Once selected, students must complete two TB skin test within a week apart; these are free and administered at the hospital. ** 2014 Jr. Volunteers will not be required to repeat the TB Skin Test. -An email will be sent with times & dates for students to have their hospital ID badge photo made. Replies to this email are required and must include the student’s preferred size for a uniform shirt (polo-style). **2014 Jr. Volunteers can wear their shirts from last year if they’re in good condition. -A mandatory orientation will be held the beginning of June; exact date, time and location TBD. -Uniform payment of $25 is due before start of program via cash or check – made out to Kingwood Medical Center. Applications are due to the hospital’s Radiology Department by May 01, 2015. ******No Exceptions****** Please Print: Check one:  New to the Jr Volunteer program at Kingwood Medical Center  Returning Jr Volunteer If returning, what was the last year you participated in our program? ____________ Your Name: _______________________________ Today’s Date: ________________________ Name of Parent or Guardian: ________________________________________________________________ Address: ________________________________________________________________________________ City: _____________________________ State: _________ Page 1 of 2 Zip: __________________ Birth Date: ________________ What will your age be as of June 1? ___________ Best phone number at which to reach you (the student): ____________________________________ Best email address at which to reach you (the student): ____________________________________ Best phone number at which to reach your parent/guardian: ____________________________________ Best email address at which to reach your parent/guardian: ____________________________________ Name of your school during 2015-2016 school year: ____________________________________ What grade were you in during the 2015-2016 school year? 8th 9th 10th 11th 12th Why do you want to be a hospital volunteer? _________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Can you devote at least 4 hours/week to volunteering with us this summer? YES NO Do you have any interest in extending your volunteering into the school year? YES NO Is there anything else you’d like us to know about you? ___________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ ********************************************************************************************************* __________________________________ Signature of Applicant __________________________________ Signature of Parent or Guardian listed on pg 1 (if applicant is younger than 18 at time of completion) Page 2 of 2