Your Information

First Name

Middle Initial

Last Name

Date of Birth

MM/DD/YYYY

Social Security Number

###-##-####

Street Address

Street Address Line 2

Apartment, suite, unit, etc.

City

State

Zip Code

Email Address

Phone Number

Preferred Method of Contact

Are You a Current College Student?

Education Information

School Name

Current Grade/Year

Expected Graduation Date

MM/YYYY

Emergency Contact

First Name

Last Name

Relationship to You

Phone Number

Alternative Phone Number (Optional)

Volunteer Experience and Preferences

Do You Have Previous Volunteer Experience at Children’s Nebraska?

What Year Did You Volunteer at Children’s?

YYYY

Do You Have Previous Volunteer Experience at Another Hospital?

Briefly Describe Your Volunteer Experience at Another Hospital

Do You Have Any Other Volunteer Experience?

Briefly Describe Your Other Volunteer Experience

Do You Have Any Hobbies, Skills, or Special Interests?

Service Area Interest(s)

(e.g., Pediatrics, Administration, Events)

How Did You Learn About Children’s Nebraska Volunteer Opportunities?

Name of Individual Who Referred You

How You Learned About Our Volunteer Opportunities

Additional Information or Comments

Availability

How many hours per week can you commit?

Do You Need Verification of Volunteer Hours And/or Activity?

Organization Name

Contact Name

First and Last Name

Contact Title

Contact Email Address

Organization Address

Street Address

Street Address Line 2

City

State

Zip Code

Note: Documentation form must be provided to Volunteer Services prior to volunteering.

Acknowledgments

Volunteer Statement of Commitment
I understand that my services are donated to Children's Nebraska and that there is no payment for the services rendered under the volunteer program. I understand that volunteering at Children’s means a commitment to a specific program and service activities. I understand that staff, patients and families will depend on me. I understand that if I am unable to attend my shift this will create extra work or reorganization by others instead of helping those who rely on me.

Confidentiality Agreement
I understand that any information that I may obtain directly or indirectly concerning patients, families, visitors, staff, Children's Nebraska or affiliates will be held absolutely confidential. If I break confidentiality of patients and/or families I may be terminated from the volunteer program.

Annual TB Skin Test and Education Review
I understand that I am responsible to complete an annual TB skin test and education review of hospital and service area information.

Photo Release
I understand that a hospital representative may take photographs of me for publications or volunteer services use during my volunteer time.

I have read the above statements. I understand the written information andconfirm that I have read and understood the above statements and agree to abide by the rules, regulations and policies of Children's Nebraska, affiliates, and the Volunteer Services Department. I understand that if I do not abide by rules, regulations and policies I may be terminated from the volunteer program.

Electronic signature indicates you read, understood, and agree to abide by the items listed above.

First and Last Name

Parent / Guardian

I have read and understand the above information and hereby give consent for my son/daughter to participate in the Teen Connection Volunteer Program at Children's Nebraska.

Parent / Guardian Signature

First and Last Name

Parent / Guardian Phone Email

Parent / Guardian Phone

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