Teen Volunteer Application

Please complete the application form if you would like to become a Wellspan Health volunteer. Once you have completed the form, click the "submit button" at the bottom.

Please Note: Submitting an application does not guarantee acceptance into Wellspan Health's Volunteer program. Your application will be reviewed and if intial qualifications are met, you will be contacted (via email or phone) to schedule an Orientation session. Once you have attended Orientation, an interview will be conducted to determine placement as well as a Health Screening and additional training (if needed).

For Teen Volunteers, a Parental Agreement for volunteering MUST be completed and signed by a parent/guaradian prior to volunteering.

Applicant Information:

Please provide your legal name (first, middle and last name; no nicknames).

Emergency Contact:

First name:

Last name:

Home phone:

* OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

School:

Please list your academic achievements, school activities, career interests, and special skills:

School & Graduation Year:

Please list School and Anticipated Graduation Year

School or Community Service Requirement:

* Community Service Requirement?:

Yes

If yes, Please list specific requirement(s) and timeframe(s):

Volunteer Interest:

Please tell us why you want to volunteer with Wellspan Health?

Volunteer Experience:

Have you volunteered in the past? If yes, please list the name of the agency, date and volunteer role.

Availability:

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Please list the number of days or hours per week you would like to serve as a volunteer.

Assignment:

Requirement:

Wellspan requires a minimum of 100 hours of Volunteer services to be completed within one (1) year from your start date.

* Are you willing to make this commitment:

Yes

If no, please explain:

Miscellaneous:

Note: A conviction record does not necessarily prevent you from volunteering for Wellspan.

* Misdemeanor or Felony Conviction?:

Yes

If yes, please list offense, type of conviction (summary, misdemeanor or felony), date(s) and location.

References:

Please provide two (2) personal adult references (one should be a teacher or guidance counselor) who can comment on your ability to serve as a volunteer. The reference cannot be relatives and they must know you for at least one (1) year. All references will be contacted.

1

2

First name:

Last name:

Email address:

Relationship:

I Agree

I hereby certify that all statements and answers set forth on the application are true and complete to the best of my knowledge. I understand that if any statements and/or answers are found false or information has been omitted, such false statements or omissions may be cause for rejection or termination of my volunteer application or service. I understand that in processing my application with Wellspan Health Volunteer Engagement, an investigative report will be conducted to obtain and verify information relating to my past activities and background. Information may include, but is not limited to: criminal records, child abuse clearances and any data provided on this application or during the intrview process. I permit the Volunteer Engagement department to use my name, photogrpah or video as a volunteer for publicity purposes when necessary.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree