Children’s Hospital Los Angeles
Application for Summer Junior Volunteer Program (15-17yrs)
This Packet Includes:
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Application
Volunteer Agreement and Parental/Guardian Consent Form
Personal Essay
Recommendation Form (Maximum of 2 and must be completed by a
teacher or a counselor) If a recommendation letter is written, it still
must be accompanied by a completed recommendation form for it to
be considered.
Please complete all required forms for your packet to be considered.
The deadline to submit your packet is:
FRIDAY, APRIL 19h at 4:00pm
Ways to submit your packet:
• Mail to: Children’s Hospital Los Angeles
Attn: Volunteer Resources, #64
4650 Sunset Blvd.
Los Angeles, CA 90027
• Fax to: (323) 361-3631
• Email to: [email protected]
• Hand Deliver to: Guest Services in the Main Hospital Lobby
Address Envelope To: Volunteer Resources
Applicants will be notified by mail beginning April 29th, 2012.
Children’s Hospital Los Angeles
Application for Summer Junior Volunteer Program (15-17 yrs)
Please type or print legibly
Last Name
Date:
First Name
Middle
Street Address
City
Zip
Birthday (Month/ Date/ Year)
Cell Phone:
Home Phone:
Social Security Number
Gender (Please circle)
M
F
-
Driver License Number and State (if applicable)
Email Address
Are you legally permitted to work in the United States?
Yes
No (Please explain)
Have you ever been convicted of a crime (other than a minor traffic violation)?
No
Yes (Please explain)
Education (Name of School)
Foreign Languages Spoken
Year
Are volunteer hours required for a class/ course or community service credit? (If yes, please explain)
Number of required service hours:_______________Required date of completion:__________________
Previous or current volunteer experience
Current Employer (if applicable)
Position
Phone
OK to call? Yes__ No__
Local Reference (Other than employer)
Occupation
Emergency Contact
Relationship
Work Hours
Phone
Phone
Assignment Preference
Our current Need is Monday – Friday between 8:00am-5:00pm
Please indicate your availability:
Day(s) of the week: Mon □ Tues □ Wed □ Thurs □ Fri □
Shift(s): Morning□ (between 8:30am-12:30pm)
Afternoon□ (between 12:30pm-4:30pm)
Volunteer Agreement and Certification of Information
Believing that Children’s Hospital Los Angeles has need of my services as a volunteer, I agree:
To hold as absolutely confidential all information which I may obtain directly or indirectly
concerning patients, parents, doctors, or personnel, and will not seek confidential information in
regard to a patient.
To commit to 3 times a week for at least 3 hours a day in a solid block of time from June 24 to
August 9.
That my services are donated to Children’s Hospital Los Angeles without contemplation of
compensation, or future employment, and given with humanitarian or charitable reasons.
I certify that the answers given by me to the foregoing questions and statements are true, correct,
and without omissions. I authorize Children’s Hospital Los Angeles to investigate and/ or verify
the foregoing information and any other information, which might assist them in determining my
qualifications for volunteering. I release Children’s Hospital Los Angeles and my former
employers, and all others from any liability from damage, which may result from such
investigation, if, upon investigation, anything contained in this application is found to be untrue.
I further agree to conform to the rules and regulations of this facility. I understand that my
volunteer status at Children’s Hospital Los Angeles can be terminated at any time for failure to
comply with the policies, rules, and regulations of the Hospital including those of the volunteer
department; for absences without notification; for reasons of unsatisfactory attitude, work or
appearance; and for any other circumstances which, in the judgment of the Hospital, would
make my continued service as a volunteer contrary to the best interests of the Hospital. I also
understand that on one has any authority to enter into any agreement for employment for any specified
period of time or to make any agreement contrary to the foregoing, except for a written employment
agreement signed by an administrative representative of this facility.
ANY PERSON WHO INTENTIONALLY GIVES MISLEADING
INFORMATION WILL BE SUBJECT TO IMMEDIATE TERMINATION.
OR
FALSE
Print Name:_____________________________________ Date: ______________________
Signature:_____________________________________________________________________________
JUNIOR VOLUNTEER PARENT/GUARDIAN CONSENT FORM
I authorize my daughter □ son □ ___________________________________ age______ to
participate in the Junior Volunteer Program at Children’s Hospital Los Angeles, and to engage in
such volunteer activities as may be assigned by the Manager, or a designated representative. I
give my permission to the Hospital for the administration of any minor treatment, should it be
deemed necessary. I release Children’s Hospital Los Angeles from any claim or liability for any
injury or illness resulting to said minor, not occasioned by any fault or neglect on the part of the
Hospital, while participating in such volunteer activities.
Signed:________________________________________________________________________
Personal Essay:
For Your application to be considered, you must complete a personal essay.
In order to be considered, your personal essay must be one full page, double-spaced and
written in size 12 Times New Roman Font.
Essay Topic: In recognizing your passion for children, please tell us why you should be
considered for a volunteer position at Children’s Hospital Los Angeles.
Children’s Hospital Los Angeles
Summer Junior Volunteer Program
RECOMMENDATION FORM INSTRUCTIONS
DEAR TEACHERS AND COUNSELORS,
Thank you for your willingness to complete the recommendation on behalf of this
candidate to volunteer for CHLA. Our Summer Junior Volunteer Program offers
mature teens an opportunity to be of service to our patients, families and staff of
Children’s Hospital Los Angeles.
Our decisions on who to accept are based on matching the needs of our Hospital. We
rely on recommendations, such as yours, in helping us identify those who will both
match and benefit from our program.
Here are some of the criteria we are looking for in a candidate:
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Has a strong need to be of service
Demonstrates an ability to “make the most” of learning opportunities
Is mature, self-directed
Is intellectually capable, although academic performance per se is not a factor in
admission
• Has demonstrated behaviors suggestive of the desire to make a positive
contribution (i.e. volunteering, tutoring)
• Demonstrates regard for others, empathy, natural courtesy in daily interactions
A prompt reply is appreciated. Please return the completed forms directly to the
applicant. Do not send directly to Children’s Hospital Los Angeles.
Thank you,
Volunteer Resources Department
Children’s Hospital Los Angeles
Summer Junior Volunteer Program
RECOMMENDATION FORM
*Please refer to the Recommendation Instructions for guidance.
NAME OF APPLICANT ________________________________________
1.
How long have you known the applicant and what is your relationship?
2.
Why do you think the applicant is applying to volunteer?
3.
4.
Based on the criteria, please identify and or describe the behaviors the applicant consistently
demonstrates.
Identify and or describe behaviors demonstrated that need improvement?
5. Please comment about the applicant’s potential for future professional success in a healthcare
field.
6.
Additional comments.
7. Summary Evaluation. Using the chart below, please rate the applicant relative to others you have
known in a similar capacity.
OUTSTANDING
EXCELLENT
GOOD
FAIR
POOR
Motivation to learn
Interest in well-being of others
Intellectual potential
Leadership potential
Judgment
Maturity
Self- Directed
Communication skills: oral
Communication skills: written
Organizational skills
Ability to analyze a problem
and formulate a solution
Relationship/Collaborative
ability to work with others
Ability to work independently
General knowledge level
Motivation for pursuing a
career in healthcare
Please Print
Name
Professional Title
School
Phone Number
Full Address
Date
Please return this form to the applicant for inclusion in their application packet. Thank you.
NOT
OBSERVED