Coaching Mentorship Career Development

Information Sheet
The Volunteer and Guest Services Office will begin accepting
applications for our Summer Program on January 4, 2016.
Acceptance is very competitive. We will review the first 75
applications and select up to 50 applicants to interview.
Please read the following information carefully, if you have questions about our
program, please contact Volunteer and Guest Services at 860-823-6320.

THE PROCESS APPLICATION FORM

Applicant completes the Junior Volunteer application form in full.
Be sure a parent or guardian also signs this application. This gives the hospital permission to
contact the teacher or guidance counselor you have chosen for your school reference.
Attach a copy of your high school student ID.
Our program is very competitive. We regret that we are not able to offer interviews to all applicants.
Only complete applications will be considered.

VACCINATIONS
For our health records, and to maintain the safety of our patients, please attach proof of:
Your first and second MMR (measles, mumps, rubella) vaccinations,
And first and second varicella inoculations or date of disease, as explained on the application.

APPLICANT INTERVIEWS
Applicants are interviewed by staff. We ask for a parent or guardian to be present. Please feel free to
ask any questions about the Bridge Program, and provide information about your interests. Be your
best at the interview. We aim to make this program as meaningful as possible, and encourage
participants to be prepared.

GUIDELINES FOR VOLUNTEERING

Applicants who are accepted into the summer program must:
Provide a recent PPD (a tuberculosis skin test), or attend our PPD clinic in June.
Attend an 8-hour orientation on Monday, June 27, 2016.
Volunteer a minimum of one eight-hour day per week after orientation through the start of school.
Not be away more than two weeks over the summer and to make up those two days away.

REV 9/8/15

FOR OFFICE USE ONLY

Interview:_____________________________________
Proof of MMR:_________Proof of Varicella:_______
Reference Sent:________________________________
Reference Returned: __________________________
Accepted Y or N: ______________________________
PPD: ______________________________

Orientation Date:______________________________

Volunteer Services
APPLICATION FOR JUNIOR VOLUNTEERS

Application Date: _______________

Only the first 75 applications
will be reviewed.

To be completed by applicant
Applicant Information (Must be a High School Student)

Name:____________________________________________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________________________________________
City/State/ZIP Code: ______________________________________________________________________________________________________________
Home Phone: ____________________________________Cell: ____________________________Email: ________________________________________
High School Grad. Year: 20_____________ Date of Birth: ____/____/____
School Information
High School: ______________________________________________________________________________________________________________________
Address:__________________________________________________________________________________________________________________________
City/State/ZIP Code: ______________________________________________________________________________________________________________
School Reference: Teacher or Guidance Counselor: ________________________________________________________________________________
Goals for volunteering (200 words or less handwritten on back): ____________________________________________________________________
__________________________________________________________________________________________________________________________________
Interests/Hobbies/Talents/Extracurricular Activities:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Is volunteering a requirement for Court Ordered Community Service? Yes No

# of hours ___________

Attach to this application a copy of your high school student ID; proof of your first and second
Measles-Mumps-Rubella inoculations, and first and second varicella (chickenpox) inoculations, titer,
or physician-verified date of disease. A physicians note on letterhead, prescription pad, or school
nurses note on schoool stationery will suffice.
Up to 50 applicants will be contacted by the Department of Volunteer and Guest Services to arrange an
interview.

I approve of my son/daughter ____________________________ volunteering his/her time at Backus Hospital and give my
permission to him/her to participate in the summer volunteer program. I also give permission for Backus Hospital to
contact the school reference listed above. I understand that the Junior Volunteer Program begins with an Orientation
on Monday, June 27, 2016, and continues through the summer months, requiring one eight-hour volunteer day per
week, and into the Fall, Winter and Spring for those students who are able to continue through the school year.
Mail Completed Application to:
Volunteer and Guest Services
Backus Hospital
326 Washington Street
Norwich, Connecticut 06360
(860) 823-6320

Signature of Parent/Guardian
Print Name of Parent/Guardian
Address
City/State/ZIP Code

Daytime Phone
E-mail address
REV 9/8/15