Not All SLHS Locations Have Youth Volunteer Programs

Dear Youth Volunteer: Thank you for your interest in the Saint Luke’s Health System (SLHS) Volunteer Program! We have an engaging program filled with a variety of opportunities for those 14 -17 years of age. Not all SLHS locations have Youth Volunteer Programs Please call the facility of choice to ascertain if a Youth Volunteer program is offered; if confirmed, schedule an interview/orientation. Bring this completed profile packet to the interview. The interview will include a discussion about our program, available opportunities, and expectations. A parent/guardian is encouraged to accompany you to the interview. To become a youth volunteer, you must complete the documents listed below/attached. ______Profile (parent/guardian signature required for youth in school 14 -17 yrs). ______Physician Form (parent/guardian/physician signatures required). Return form via mail or fax to the appropriate SLHS Facility.

A TB test and an Influenza Vaccination (within the past 12 months) is required. These tests can be acquired from your physician or Health Department. SLHS can provide the TB test at no cost if the youth is accepted to volunteer. The Physician can include the TB and Influenza Vaccination documentation on the Physician Form, if available. ______Volunteer Reference Forms (2

SAINT LUKE’S HEALTH SYSTEM CARE FACILITIES

Cushing Memorial Hospital Saint Luke’s East Saint Luke’s North 711 Marshall 100 NE Saint Luke’s Blvd. 5830 NW Barry Road Leavenworth KS 66048 Lee’s Summit MO 64086 Kansas City MO 64154 913.684.1310 816.347.4930 816.880.6083

Saint Luke’s Plaza Saint Luke’s South SL Hospice/Hospice House 4401 Wornall Road 12300 Metcalf Avenue 3100 Broadway, Suite 1000 Kansas City MO 64111 Overland Park KS 66213 Kansas City, MO 64111 816.932.2448 913.317.7405 816.756.1160

Hedrick Medical Center 2799 N. Washington St. Chillicothe, MO 64601 660.646.1480 In submitting this profile, I understand that I will receive no remuneration for the volunteer services I provide. I agree to maintain confidentiality concerning all guest information and adhere to the policies and procedures that have been established by Saint Luke’s Health System. I understand, as a hospital volunteer, I am required to provide TB Test and Influenza Vaccination documentation and I give permission to Saint Luke’s Health System to contact my physician, references, and to conduct a personal background check. I understand SLHS no longer selects individuals who use any tobacco, nicotine, e-cigarettes or vaping products and I represent and agree I do not currently and will not use any of said products as a volunteer of SLHS. I do understand that I cannot smoke or use said products on campus or on parking lots of the facility. Non-compliance of this policy is grounds for immediate dismissal of volunteer responsibilities I hereby certify that the information contained in this profile is true, complete and correct. I understand that all information contained in my volunteer profile will be kept confidential.

Vs 6.14.1

PROSPECTIVE YOUTH VOLUNTEER PROFILE

Information About You First Name Middle Name Last Name Street Apt. # City State Zip Code Home Ph# Cell Ph# Email Date of Birth Age Social Security # (xxx -12-3456) (last 6 digits only) Physician Phone Physician Name

Information About Your Parent(s)/Guardian I live with my (check all that apply) Parent Parent Guardian Parent/Guardian Name Home Ph# Work Ph# Cell Ph# Email Parent/Guardian Name Home Ph# Work Ph# Cell Ph# Email

Your Current Activities Name of School School Ph# Last Grade Completed School Activities Employer and Job (if employed) Typical Work Schedule Volunteer Experience Other school, work, church or other activities/experience

Volunteering at Saint Luke’s Health System Please write a paragraph stating the reasons you want to volunteer (use reverse page if needed).

Vs6.14.2

2 YOUTH VOLUNTEER PROFILE Volunteering at Saint Luke’s Health System, continued How did you hear about our volunteer program? Your skills Babysitting Computers Mentoring Other: Your language(s) English Spanish French German Other: Your Interests Clerical Patient Contact Errands Nursing Child Care Other:

When are you available to volunteer? Check all that apply. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon Evening Please list two Personal References (not related to you) Name Street/City/Zip E-mail: Name Street/City/Zip E-mail: Do you have any of these health issues? Check all that apply. Allergies Arthritis Asthma Back Problems Diabetes Epilepsy Fainting Spells Foot Problems Hearing Problems Heart Problems Hepatitis High Blood Pressure Mental Illness Tuberculosis Other Infectious Conditions Do you have any limitations which would affect the type of volunteer position assigned? No Yes Explain List medications taken regularly At Which Saint Luke’s Health System Location do you wish to volunteer?

Cushing Memorial Hospital Saint Luke’s East Saint Luke’s North 711 Marshall 100 NE Saint Luke’s Blvd. 5830 NW Barry Road Leavenworth KS 66048 Lee’s Summit MO 64086 Kansas City MO 64154 913.684.1310 816.347.4621 816.880.6083

Saint Luke’s Plaza Saint Luke’s South SL Hospice/Hospice House 4401 Wornall Road 12300 Metcalf Avenue 3100 Broadway, Suite 1000 Kansas City MO 64111 Overland Park KS 66213 Kansas City, MO 64111 816.932.2005 913.317.7405 816.756.1160

Hedrick Medical Center 2799 Washington St. Chillicothe, MO 64601 660.646.1480

Vs 6.14.3

YOUTH VOLUNTEER COMMITMENT: As a Youth Volunteer for Saint Luke's Hospital, I understand I will receive no remuneration for my services. I give permission to contact references if necessary. Should I be unable to volunteer as scheduled, it is my responsibility to notify Volunteer Services. I understand that I will receive no remuneration for the volunteer services I provide. I agree to maintain confidentiality concerning all guest information and adhere to the policies and procedures that have been established by Saint Luke’s Health System. I understand I am required to provide TB Test and Influenza Vaccination documentation and my parent give permission to Saint Luke’s Health System to contact my physician, references. Cell phone use will be limited while volunteering. I understand SLHS no longer selects individuals who use any tobacco, nicotine, e-cigarettes or vaping products and I represent and agree I do not currently and will not use any of said products as a volunteer of SLHS. I do understand that I cannot smoke or use said products on campus or on parking lots of the facility. I hereby certify that the information contained in this profile is true, complete and correct. I understand that all information contained in my volunteer profile will be kept confidential. Non-compliance to comply with policy, these commitments and expected behaviors in the Youth Volunteer Program will result in termination from my duties as volunteer. YOUTH SIGNATURE:______DATE:______* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PARENT/GUARDIAN PERMISSION In signing this document, I give permission for the youth named on this profile to participate in the Saint Luke's Health System Youth Volunteer Program and other facility sponsored activities. I verify the youth is 14-17 years of age and the information on this profile is correct. I understand that all of the profile packet’s information will be kept confidential and is for office or emergency use only.

I am responsible for the purchase of a uniform. I take responsibility for the youth’s transportation, prompt arrival and departure for his/her scheduled shift. I understand it is the responsibility of the youth to notify Volunteer Services of changes.

I will provide TB Test and Influenza Vaccination documentation from a physician, Health Department or give permission for the youth to receive a TB skin or blood test administered by SLHS (no cost). I am responsible for the provision of a completed Health Statement & Physician Form. In the event of illness or injury and I am not available, the physician listed on this profile will be notified for treatment. Should the physician be unavailable, I give permission for the youth to receive appropriate emergency care.

DATE:______PARENT/GUARDIAN:______(Required for students in school 14 - 17 yrs) RELATIONSHIP:______

NONDISCRIMINATION AND EQUAL OPPORTUNITY STATEMENT

It is the policy of Saint Luke's Health System not to discriminate in admissions or access to, or treatment or employment in its program and activities, or in the granting, maintaining, upgrading and withdrawal of physician staff privileges for any unlawful reason, such as race, color national origin, sex, age, or handicap in violation of Section 504 of the Rehabilitation Act and applicable regulations. Responsible employee: Administration Director of Civil Rights - 816-932-3820 ************************************************************************************************************************FO R OFFICE USE ONLY INTERVIEW DATE/TIME ______BY______

[ ] Physician Form [ ] TB Documentation / [ ] 2nd Screening (as required) [ ] Flu Shot [ ] Orientation/Video

[ ] I.D. Badge [ ] Uniform/Shirt Received [ ] Fees Rec’d [ ] 1st [ ] 2nd Reference Received

Assignment______/______/______(Day) (Time) (Position REMARKS:______Starting Date: ______Time:______Vs6.14.4

4 PROSPECTIVE YOUTH VOLUNTEER PHYSICIAN’S FORM

Youth Name ______SS# (if req’d by Physician)______I authorize release of the following information to Saint Luke’s Health System.

______Prospective Volunteer’s Parent / Legal Guardian Signature Date Specify location/s below

Hedrick Medical Center Cushing Memorial Hospital Saint Luke’s East Fax# 660-214-8136 Fax# 913-758-1894 Fax# 816-347-4626

Saint Luke’s Northland Saint Luke’s Plaza Saint Luke’s South Fax# 816-880-6358 Fax# 816-932-3888 Fax# 913-317-7404

SL Hospice/Hospice House Fax# 816-756-2596

------This section to be completed by Physician ------Please Fax information requested to the location/s specified above. ______I see no medical reason why this person should not volunteer. ______This person should volunteer with the following restrictions. ______This person should not be a volunteer in a healthcare facility. TB documentation (last 12 months) is required for all volunteers. (The TB Test and Influenza Vaccination can be acquired by the Physician or Health Department. The Saint Luke’s System Hospital you choose to volunteer can provide the TB test.) ______Date of TB test (last 12 months) if available or ______Date of chest x-ray indicating free of active Tuberculosis (last 12 months) If x-ray is contraindicated, please comment (below) on follow-up & whether this person will pose hazard to others.

______Date of Influenza Vaccination with in last 12 months.

______Signature of Physician Printed Name of Physician

______/____/______/___/___ Address/ City/State/Zip Phone Date Vs 6.14.5

YOUTH VOLUNTEER PERSONAL REFERENCE

______has applied to volunteer at a Saint Luke’s Health System facility and has given you as a personal reference. Please complete this form and return to the perspective youth volunteer. Thank you for your help.

Coordinator/ Youth Volunteers

VOLUNTEER REFERENCE

Name of Reference______

Relationship to Applicant (not a relative)______

How long have you known the applicant? ______

Explain how the applicant demonstrates they are responsible/dependable?______

______

Why would you recommend the applicant as a volunteer for Saint Luke’s Health System? _____

______

Additional Comments ______

______

Signature of Reference ______Date ______

Telephone #/ Email ______(Optional) Vs 6.14.6

YOUTH VOLUNTEER PERSONAL REFERENCE

6 ______has applied to volunteer at a Saint Luke’s Health System facility and has given you as a personal reference. Please complete this form and return to the perspective youth volunteer. Thank you for your help.

Coordinator/ Youth Volunteers

VOLUNTEER REFERENCE

Name of Reference______

Relationship to Applicant (not a relative)______

How long have you known the applicant? ______

Explain how the applicant demonstrates they are responsible/dependable?______

______

Why would you recommend the applicant as a volunteer for Saint Luke’s Health System? _____

______

Additional Comments ______

______

Signature of Reference ______Date ______

Telephone #/ Email ______(Optional) Vs 6.14.7