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Youth Volunteer Application

* Required Info

First Name:

Last Name:

Address:

City:

State:

ZIP:

Phone:

Email:

Legal Guardian:

Guardian's relation to youth:

Guardian's phone:

In case of emergency, notify:

Name:

Phone:

Relationship:

Tell us a little about you and your interests:

Age:

What grade level will you be in the fall?:

What school do you attend?:

Skills and special interests:

Why are you interested in volunteering?:

What career ambitions do you have?:

Two letters of reference from adults that are not relatives.

The reference letters can be attached to this form, or they can be emailed directly to: William.McCann@bhsi.com

Reference Letter#1
Upload a reference letter (PDF):

Reference Letter #2
Upload a reference letter (PDF):

Please list any medical conditions we should be aware of:

If you do not have any medical conditions, please put N/A or None.

Will you have transportation to and from the hospital? :

What is your availability?

Days of the week available:

Hours available:

Hospital Requirements
The hospital requires either a TB test or proof that you have received one in the past 9 months. Each person must attend hospital orientation which includes signing a letter of confidentiality.

Youth Agreement
As a member of the Youth Volunteers at Baptist Health Deaconess Madisonville, I agree to be faithful and abide by the rules and regulations. I agree to be courteous, dependable and obedient at all times, to uphold the code of ethics and to perform faithfully, to the best of my ability, all duties, which are assigned to me.

Youth Signature:

Parent/Guardian Authorization
I/we hereby agree to allow our son/daughter/ward to serve as a Youth Volunteer at Baptist Health Deaconess Madisonville. I fully understand that in the course of his/her duties, my son/daughter/ward may be permitted to enter patient areas of the hospital.

I/we hereby release, discharge and relieve Baptist Health Deaconess Madisonville from any and all claims whatsoever of any nature arising out of and as a result of his/her service at Baptist Health Deaconess Madisonville.

Parent/Guardian Signature:

Must be entered by parent or legal guardian