2017 – 2018Teen Leadership ProgramApplication

For Students in Grades 10th-12th

Application Deadline: June 15, 2017

Typed applications preferred, or please print: (Illegible applications will not be processed)

Name ______

Date of Birth ______Age ______Grade in High School (fall 2017) ______

Name of High School ______Male ___ Female

Address ______City______Zip______

Email ______Last 4 digits of social security number ______

Home Phone ______Cell Phone ______

Emergency Contact ______Relationship ______

Best Contact Phone ______Alternate Phone ______

Extracurricular school clubs or sports this next year:

Club/Sport / Days/Times

Other activities this next year (church, youth group, work, etc.)

Club/Sport / Days/Times

Please describe prior volunteer experience:

______

Please describe prior work experience:

______

On a separate piece of paper, please answer the following questions - limit 2 pages total:

1)Why would you like to participate in this program?

2)What does leadership mean to you and how will you use it as a volunteer here?

3)What does accountability mean to you and how will you use it as a volunteer here?

4)Describe a time you received constructive criticism on a project. How did you handle it?

5)What attributes will you bring to this program?

Applicants willbe asked to come to the hospital for a 15 minute interview. Please check alldays and times you would be available to come in for this interview:

___ W 6/28/17 1:00 p.m. ___ W 6/28/17 1:15 p.m. ___ W 6/28/17 1:30 p.m.

___ W 6/28/17 1:45 p.m. ___ W 6/28/17 2:00 p.m. ___ W 6/28/17 1:15 p.m.

___ W6/28/17 2:30 p.m. ___ W 6/28/17 2:45 p.m.

___ T7/11/17 10:00 a.m. ___ T7/11/17 10:15 a.m. ___ T7/11/1710:30 a.m.

___ T7/11/1710:45 a.m. ___ T7/11/1711:00 a.m. ___ T7/11/1711:15 a.m.

___ T7/11/1711:30 a.m. ___ T7/11/1711:45 a.m. ___ T7/11/1712:00 p.m.

___ Th 7/13/171:00 p.m. ___ Th 7/13/171:15 p.m. ___ Th 7/13/171:30 p.m.

___ Th 7/13/17 1:45 p.m. ___ Th 7/13/17, 2:00 p.m. ___ Th 7/13/172:15 p.m.

___ Th 7/13/172:30 p.m. ___ Th 7/13/17, 2:45 p.m. ___ Th 7/13/173:00 p.m.

___ T 7/18/17 10:00 a.m. ___ T 7/18/1710:15 a.m. ___ T 7/18/1710:30 a.m.

___ T 7/18/1710:45 a.m. ___ T 7/18/1711:00 a.m. ___ T 7/18/1711:15 a.m.

___ T 7/18/1711:30 a.m. ___ T 7/18/1711:45 a.m. ___ T 7/18/1712:00 p.m.

___ Th 7/20/172:00 p.m. ___ Th 7/20/172:15 p.m. ___ Th 7/20/172:30 p.m.

___ Th 7/20/172:45 p.m. ___ Th 7/20/173:00 p.m. ___ Th 7/20/173:15 p.m.

___ Th 7/20/173:30 p.m. ___ Th 7/20/173:45 p.m. ___ Th 7/20/174:00 p.m.

All applicants will be notified on Friday, 7/27/17.

I understand the commitment involved in participating in the P/SL Teen Volunteer Leadership Program. I am available for the training dates and will consistently be at the volunteer shift I select.

Student Signature ______Date ______

I understand the commitment involved in participating in the P/SL Teen Volunteer Leadership Program and will support my child in this endeavor. This includes promoting consistent attendance and transportation. I also understand that my child will need to go through a background check, have 2 TB tests and have a flu shot later in the fall.

I/we ______will attend the first training session on Thursday, 8/29/16 from 5:00 – 6:30 p.m. (required).

Parent/Guardian Signature ______Date ______

Application Materials Checklist – Incomplete applications will not be considered:

Application Completed

Questions Answered (from application)

Teen Contract

Background Check

Shift Form

All Original Signatures

Social Security Card (bring to interview to be copied)

Please return all materials at one time by June 15, 2017to:

Teen Leadership Program

Presbyterian/St. Luke’s Medical Center

1719 E. 19th Ave.

Denver, CO 80218

or

Scan and Email to

Teen Leadership Program Schedule

Name ______

Please check at least three shifts you would be available for beginning the week of September 21st ending on May 31st.

Thank you!

First Semester

___ Mondays4:00 – 8:00 p.m.

___ Tuesdays4:00 – 8:00 p.m.

___ Wednesdays4:00 – 8:00 p.m.

___ Thursdays4:00 – 8:00 p.m.

___ Fridays4:00 – 8:00 p.m.

___ Saturdays9:00 a.m. – 1:00 p.m.

___ Saturdays1:00 – 5:00 p.m.

___ Sundays9:00 a.m. – 1:00 p.m.

___ Sundays1:00 – 5:00 p.m.

Second Semester

___ Mondays4:00 – 8:00 p.m.

___ Tuesdays4:00 – 8:00 p.m.

___ Wednesdays4:00 – 8:00 p.m.

___ Thursdays4:00 – 8:00 p.m.

___ Fridays4:00 – 8:00 p.m.

___ Saturdays9:00 a.m. – 1:00 p.m.

___ Saturdays1:00 – 5:00 p.m.

___ Sundays9:00 a.m. – 1:00 p.m.

___ Sundays1:00 – 5:00 p.m.

TEEN LEADERSHIP VOLUNTEER CONTRACT

Thank you for your interest in serving as a teen volunteer at Presbyterian/St. Luke’s Medical Center. We take pride in providing teen volunteers with opportunities to observe healthcare professionals in action. As such, we will make every effort to support you in a positive and rewarding experience at P/SL.

To ensure your understanding of the commitment involved, please read the following statements, and sign below in the space provided.

While volunteering at Presbyterian/St. Luke’s Medical Center, I will:

  • Bring the best of who I am to my volunteer service.
  • Meet my volunteer commitments in a professional and courteous manner.
  • Dress neatly according to the dress code (i.e. no jeans, bare midriff, spaghetti straps, mini skirts, platform or open toed shoes).
  • Maintain a positive “can do” attitude at all times.
  • Demonstrate courtesy and respect towards patients, families, staff and fellow volunteers.
  • Follow policies and procedures as outlined in Volunteer Orientation.
  • Keep absolutely confidential any information regarding patients, families and staff as described in Volunteer Orientation.
  • Avoid making personal phone calls and/or texts while on volunteer duty.
  • Not bring my friends to the hospital while I am volunteering.
  • Discuss any problems, criticisms or suggestions for program improvement with the Volunteer Services staff.
  • Understand that any inappropriate action on my part can result in dismissal from the program.

Additionally, if I cannot attend on the day for which I am scheduled, I will contact the Volunteer Services Department as soon as possible.

Name of Student______Date______

(Please print.)

Signature of Student______

Signature of Parent or Guardian______