Parental Agreement

PARENTAL AGREEMENT

I am the parent/guardian of:

Student Name: ______

Telephone Number: ______

By signing this agreement:

 I am aware that my son/daughter must commit to a minimum of 40 hours to be completed before graduation and that the high school Community Service Form will not be signed until the 40 hour minimum requirement is met.  I understand that my son/daughter must not be away for more than 2 weeks this summer.  I will ensure that my son/daughter understands that volunteering is a serious commitment and will report on time and on the day(s) assigned.  MidState strictly enforces a professional dress code, therefore students must report for duty dressed in appropriate attire (no jeans, shorts, capris, or sandals.) (Students will be sent home if dressed inappropriately or not wearing their uniform shirt or badge.)  I am aware that as a MidState volunteer, my son/daughter represents not only themselves, but their school and MidState Medical Center, and must demonstrate appropriate behaviors at all times when on duty or will be subject to dismissal if deemed necessary.  I understand that if my son/daughter is accepted into the Summer Program, the Health Clearance form and PPD (TB testing) will be completed by a physician.  I will ensure that my son/daughter meets all necessary requirements on or before the deadlines and ensure attendance at the mandatory Safety Orientation scheduled for: Monday June 12, 2017 9am – 1pm.  I understand that there is the possibility that my son/daughter may not be accepted into the Volunteer Program at this time if there is no position available and may be placed on a waiting list.

______Parent/Guardian Signature Date

Your signature on this agreement will serve as your acknowledgement of the requirements of MidState Medical Center’s Teen Volunteer Program. If you have any questions or concerns, please do not hesitate to contact me at 203-694-8572. We anticipate that our student volunteers will have a rewarding and positive experience at MidState Medical Center.

(Please attach this signed copy to the Teen Application Packet and send to Volunteer Office. Keep one copy for your records.)

Sincerely,

Diamond A. Belejack

Diamond A. Belejack, CAVS, Central Region Manager Volunteer Services