2015 Junior Volunteer Program
Thank you for your interest in participating in Schneck’s summer Junior Volunteer Program.
Applications and required documents will be available May 1-May 28, 2015 at
www.schneckmed.org/givingback.
Important Dates:
May 28, 2015 – Mandatory registration in Classroom 3 (just inside the Visitor’s Entrance)
anytime between 5 and 7 p.m. Bring with you all required paperwork, receive a tuberculin skin
test (TST), purchase your polo for $15, and receive your volunteer handbook. You must have all
required paperwork turned in that evening to participate in the program.
June 4, 2015 – Mandatory information session from 12 to 4 p.m. in Classroom 3. You will also
receive your second of two TSTs.
Please review the following mandatory program guidelines. (Some guidelines are new for 2015.)
 You must be at least 14 years of age and completing 8th grade.
 You must be able to complete at least 28 volunteer hours throughout the summer. This
would consist of one scheduled 4-hour shift per week.
 You must submit a current copy of your immunization record (even if you were a past
junior volunteer).
 You must submit a letter of recommendation from a current school teacher, pastor, etc.
 You must be available to have both of the TSTs read between 48 and 72 hours after
receiving the test. If you were a past junior volunteer, you will not need to receive a TST
test this year.
 You may request a specific area to volunteer. We will try to accommodate your request
based upon area need.
 Our summer schedule begins Monday, June 8, 2015.
The guidelines and dates are mandatory in order for the volunteer program to accommodate
the influx of junior volunteers. No exceptions will be made.
The Schneck Guild award up to three $1,000 scholarships annually to graduating seniors that
have been past junior volunteers and plan on pursuing a career in healthcare. Qualifying
applicants may apply in March 2016. More information will be available on Schneck’s website
closer to the application deadline.
Please feel free to contact me if you have any questions!
Amy Cockerham, Volunteer Manager
(812)522-0439 | [email protected]
2015 Junior Volunteer Application
NAME: __________________________________________________________
Last
First
Middle
ADDRESS: _______________________________________
_______________________________________
EMAIL ADDRESS: _________________________________
GENDER:  MALE  FEMALE
AGE:_________
DATE OF BIRTH: _______________
HOME PHONE: __________________ CELL PHONE: __________________
MOTHER’S INFORMATION
NAME: _____________________________
HOME PHONE: _________________ WORK PHONE: __________________ CELL PHONE: __________________
FATHER’S INFORMATION NAME: ______________________________
HOME PHONE: _________________ WORK PHONE: __________________ CELL PHONE: __________________
EMERGENCY CONTACT INFORMATION
NAME: ________________________________________ RELATIONSHIP: _______________________
PHONE NUMBER: ______________ ADDRESS: _____________________________________________
VOLUNTEER INFORMATION
SCHOOL ATTENDING & GRADE COMPLETING: ______________________________________________
HAVE YOU VOLUNTEERED AT SCHNECK MEDICAL CENTER PREVIOUSLY?  YES  NO
IF YES, WHEN: _______________________________________________________________________
HAVE YOU VOLUNTEERED AT ANY OTHER SERVICE AGENCY OR CHURCH?  YES  NO
IF YES, WHERE AND WHEN: _____________________________________________________________
PLEASE GIVE A BRIEF DESCRIPTION OF WHY YOU ARE INTERESTED IN VOLUNTEERING AT SCHNECK
MEDICAL CENTER: ____________________________________________________________________
____________________________________________________________________________________
Please answer the following questions completely. Your answers in the next section will determine
the schedule you are assigned, which will be distributed at the mandatory training session. Once this
schedule is complete, it will be difficult to make adjustments, and may result in not having a
volunteer position available.
WHICH DAY OF THE WEEK DO YOU PREFER? ________________ Time:  8-12
 12-4
 4-8
Time:  8-12
 12-4
 4-8
WHICH DAY IS YOUR SECOND CHOICE? ____________________
ARE THERE DATES THAT YOU ARE UNABLE TO VOLUNTEER? __________________________________
WHAT AREA WOULD YOU MOST PREFER TO VOLUNTEER IN? _________________________________
We will need a copy of your shot record even if you have been a junior volunteer in the past. We will be
checking to make sure you have had all series for Hepatitis B, Varicella, and MMR. You will be required
to have two tuberculin skin tests (TSTs) unless you were a past junior volunteer. The first test will be on
Thursday, May 28 when you drop off your application information. The test must be read on Sunday,
May 31 before 5pm. The second test will be during the mandatory orientation on Thursday, June 4 and
must be read between Saturday, June 6 after 12pm and Sunday, June 7 before 12pm.
YOU ARE REQUIRED TO ATTEND THE MANDATORY ORIENTATION SCHEDULED ON JUNE 4 FROM
12PM-4PM IN CLASSROOM 3. IF YOU ARE NOT ABLE TO ATTEND THE ORIENTATION, YOU WILL NOT
BE ABLE TO VOLUNTEER. NO EXCEPTIONS WILL BE MADE.
You will be given a copy of the Junior Volunteer Handbook on Thursday, May 28. Please read it
thoroughly and bring it to your orientation on Thursday, June 4. You will purchase your volunteer polo
on May 28 for $15. The full uniform must be worn to the orientation on Thursday, June 4. Full uniform
includes your polo, khaki pants, and clean tennis shoes.
Please use the following checklist to make sure you have everything filled out properly and included
in the application packet when you bring it on Thursday, May 28. You will not be eligible for the
program if you do not have all paperwork complete and turned in that evening.
Application Form
Parent’s Agreement
Vaccination Record (even if you have volunteered in the past)
Recommendation Letter (from someone other than a family member)
All signatures complete
____________________________________________
JUNIOR VOLUNTEER SIGNATURE
__________________________________
DATE
BY SIGNING BELOW, I CONSENT TO MY SON/DAUGHTER RECEIVING THE REQUIRED TUBERCULIN SKIN
TESTS AND VALIDATING ANY OF THE ABOVE INFORMATION TO BE TRUE.
____________________________________________
PARENT OR GUARDIAN SIGNATURE
__________________________________
DATE
Please contact Amy Cockerham, Volunteer Manager, by calling (812) 522-0439 if you have any
questions. Thank you for following our strict guidelines. They are necessary to accommodate such a
large group for such a short period of time.
PLEASE RETURN THIS APPLICATION TUESDAY, MAY 28 IN CLASSROOM 3 AT SCHNECK MEDICAL
CENTER ANYTIME BETWEEN 5 AND 7PM. Enter the hospital through the entrance closest to Tipton
Street and the Gift Shop. In addition to receiving your first TST, be prepared to also purchase your
Volunteer polo for $15 that evening.
JUNIOR VOLUNTEER PROGRAM
PARENT AGREEMENT
I give my permission for my daughter/son _______________________________ to participate in the
Junior Volunteer Program at Schneck Medical Center. I realize the responsibilities of the organization,
and will cooperate with my child to comply with the rules and regulations which have been adopted. I
will see that the times he/she is scheduled to work are kept free of interfering activities if possible, and
will assume responsibility for their transportation and the purchase of a volunteer’s uniform.
My child’s health is such that I feel they are physically able to fulfill the obligations of volunteer service.
I understand that in the course of their duties, he/she will enter patient areas of the hospital.
In consideration of the opportunities extended to my child under the Junior Volunteer Program, I
hereby release, remit, discharge, and relieve Schneck Medical Center from any and all claims of
whatever nature on behalf of my child, arising out of and as a result of his/her service at Schneck
Medical Center.
___________________________________________
Parent or Guardian Signature
_______________
Date
JUNIOR VOLUNTEER AGREEMENT
As a Junior Volunteer, I agree to serve regularly each week at Schneck Medical Center and to abide by
the rules and regulations which have been adopted. I agree to be courteous and dependable at all
times, and to perform faithfully to the best of my ability all duties which are assigned to me.
___________________________________________
Junior Volunteer Signature
_______________
Date
Please return this signed form with your application on May 28, 2015.