Thank you for your interest in the Summer 2022 VolunTEEN Program at Vidant Medical Center. Please complete and submit this application form. Remember, this program is for students ages 15-17. You must be at least 15 years of age and complete with the 9th grade by June 11th 2022. Students who are graduating seniors this year are NOT eligible for the program. Please do not apply if you are graduating high school this year. VolunTEENS must have completed their COVID vaccination(s).  Reference forms and interviews will be extended after the application deadline on February 4th 2022. Thank you!


Personal Information

Please enter your name and address as it appears on legal documents.


Parent/Guardian Information

You must have at least one parent/guardian listed. Duplicate if necessary.


Availability and Interest

All volunteer positions require a minimum of four (4) hours of service once a week. Please indicate the days and times you are usually available to volunteer. You may also choose specific areas of interest. Please Note: The James and Connie Maynard Children's Hospital is not a placement option for new volunteens.


Limitations

Do you have any physical limitations or are you under a doctor's care for any illness?


Final Question

If there is anything you would like us to know that we did not ask you before, you may state it here.


Applicant Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteen, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate termination.


Acknowlege & Release: Substance Prevention Policy

I have been informed and acknowledge that Vidant (VH) and its subsidiary corporate entities have a Substance Abuse Prevention Policy which includes a Zero Tolerance Provision. I understand that applicants for positions with these corporations may receive pre-employment drug screening as part of the hiring process and that hiring decisions are contingent upon results.

I specifically consent and agree to provide bodily fluid samples (blood and/or urine) for drug and/or alcohol screening in accordance with the policy as part of the application process.

I understand that if I am not accepted because of a positive drug screen, I will not be reconsidered for volunteer service at VH or any of its subsidiary corporate entities until I can document twelve (12) continuous months of treatment for drug abuse.

I understand and specifically consent and agree that any positive drug screening results will be furnished to the appropriate Volunteer Department and to my professional licensing board, if appropriate. I further understand that once accepted, subsequent positive screens or refusal to provide samples when requested will make me subject to disciplinary action up to and including termination.


Confidentiality Statement

Vidant Medical Center has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my assignment at Vidant Medical Center, I may come into possession of confidential patient information even though I may not be directly involved in providing patient services. I understand that such information must be maintained in the strictest confidence.

As a condition of my assignment, I hereby agree that I will not at any time during or after my assignment disclose any patient information. When patient information will be discussed with health care practitioners in the course of my assignment, I will use discretion to assure that such conversations will not be held in a public place or with inappropriate individuals.

I understand that violation of this agreement may result in termination of my assignment at Vidant Medical Center.


Consent Waiver and Release

I hereby give permission to Vidant Health, and its subsidiaries and affiliated entities, including, but not limited to Vidant Medical Center; Vidant Health Foundation, Inc. d/b/a Vidant Medical Center Foundation, Inc. d/b/a Vidant Health Foundation, Inc.; HealthAccess, Inc.; SurgiCenter of Eastern Carolina, LLC d/b/a Vidant SurgiCenter; Vidant Health Physicians, LLC d/b/a Vidant Medical Group; East Carolina Health d/b/a Vidant Community Hospitals; East Carolina Health-Beaufort, Inc. d/b/a Vidant Beaufort Hospital; East Carolina Health-Bertie, Inc. d/b/a Vidant Bertie Hospital; East Carolina Health-Chowan, Inc. d/b/a Vidant Chowan Hospital; East Carolina Health-Heritage Inc. Vidant Edgecombe Hospital; East Carolina Health d/b/a Vidant Roanoke-Chowan Hospital; Duplin General Hospital, Inc. d/b/a Vidant Duplin Hospital; The Outer Banks Hospital, Inc.; and collectively “Vidant Health entities,” to record, reproduce, publish, print, film, photograph, video, prepare, use or exhibit in any form whatsoever, including but not limited to electronically or digitally, by name, picture, image, portrait, likeness, voice, or any and all of them for the use noted below and without by prior examination of the finished product.

Any picture, portrait, photograph, photo transparency, audiovisual illustration, computer file, electronic image or other likeness constitutes the property of the Vidant Health entities and may be used without prior examination of the product.

I hereby waive my rights (or my child’s rights) to privacy in connection with the consent given above and I hereby voluntarily waive, release discharge and agree to defend, indemnify and hold harmless Vidant Health entities, each of their successors, assigns, affiliates and subsidiaries; each of their directors, officers, trustees, agents and employees from any liability for any and all claims or causes of action I, my heirs or assigns might now or hereafter and further agree that this consent will not be made the basis of a future claim of any kind.

By affixing the signature below, I hereby certify that I have read and understand this CONSENT WAIVER AND RELEASE.


Disclosure/Authorization Statement

By this document, Vidant Health (VH) and its subsidiary corporate entities disclose to you that a consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment.

This shall authorize the procurement of a consumer report by VH and its subsidiary corporate entities as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the appropriate corporate entity by which I am employed to procure consumer reports at any time during my employment period.

In connection with this request, I authorize all corporations, companies, former employers, supervisors, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts, motor vehicle bureaus, military services and persons to release information they may have about me to the corporate entity of Vidant Health with which this form has been filed or an agent acting on its behalf and release all parties involved from any liability and responsibility for doing so.

This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested.

I understand that I have the right upon written request within a reasonable period of time, to request additional disclosure as to the nature and scope of the investigation.

I authorize the National Personnel Records Center, St. Louis, MO or other custodian of my military records to release to the corporate entity of VH to which I am applying or its agent acting on its behalf, information, or photocopies of my military personnel and related medical records or only the following information/records: