Teen Volunteer

Street Address *

Family Physician

Please identify all skills and abilities that apply. Also note any special skills and knowledge that might be pertinent for the volunteer position desired.

Computer Skills (check all that apply)

Any additional computer knowledge/skills:

Additional Skills and Talents (i.e., multi-lingual, theatrical skills, photography, artistic ability, hobbies/crafts, etc.)

These questions are designed to help determine the best fit for you in our organization. Please give short responses (two paragraphs or less) to the following questions.

Describe a previous volunteer experience that you have held. Did it involve a leadership role? What did you like most and least about the experience?

Why do you want to be a Hospice & Palliative Care Charlotte Region Teen Volunteer?

My parent or guardian (insert name)*supports this application and can be reached at (insert number)*for verification.

All new teen volunteers with Hospice & Palliative Care Charlotte Region must be administered two TB tests prior to working with patients. These tests are available at no charge. The first test is administered with results evaluated 48 to 72 hours later. The second test is administered two weeks after the first. Your signature below authorizes Hospice & Palliative Care Charlotte Region to administer the required TB Screening for your teen.

At times, information concerning a volunteer may be used in a press release, for fundraising purposes, or other reasons deemed appropriate by Hospice & Palliative Care Charlotte Region. Submission of this application provides consent for Hospice & Palliative Care Charlotte Region to use the teen volunteer’s name, title, portrait, picture, video image, photograph, or any reproduction likeness or quotation of the teen volunteer’s remarks for public information, fund-raising purposes, or other organizational programs as approved by Hospice & Palliative Care Charlotte Region.

Please read the following statements with your teen volunteer applicant and sign below:

• Teens under 18 years old are not allowed to transport patients or their family members by auto.
• Universal Precautions taken by medical personnel when working with all patients and Infection Control are taught during volunteer training.
• All patient information is confidential. Since your child may share information with you concerning their volunteer experience, your signature below indicates that you will keep in confidence any information shared with you about a Hospice & Palliative Care Charlotte Region patient.
• All Teen Volunteers must document each visit with patient/family. This documentation becomes part of the medical record which is an integral part of the Hospice & Palliative Care Charlotte Region plan of care for the patient and facilitates government funding.
• HPCCR Volunteers are expected and required to report on time for accepted assignments and in appropriate mental and physical condition for work. It is our intent to provide a healthful, safe, and secure work environment. However, as a volunteer with Hospice & Palliative Care Charlotte Region (HPCCR), I understand that I am volunteering at my own risk whether at an HPCCR facility, third party facility, special event, patient homes, or while commuting. I understand that HPCCR is not liable for any claim that I may have with respect to any bodily injury, personal injury, illness, death, or property damage that may result from volunteer activities whether caused by the negligence of HPCCR or its board of directors, employees, agents or otherwise. I also understand that HPCCR does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.
• The information provided has been completed thoroughly and truthfully by the Teen Volunteer Program applicant. This application and any other documents obtained during the application process will remain confidential in the HPCCR Volunteer Services Office.