Personal Information
Last Name:
First Name:
Street:
City/State/Zip:
Home Phone:
Cell Phone:
E-Mail:
Date Of Birth (MM/DD/YY):
Current Year Of High School:

Parent/Guardian
Name:
Relationship:
Street:
City/State/Zip:
Work Phone:

Emergency Information (if different from parent/guardian)
Contact:
Relationship:
Cell Phone:
Home Phone:
Business Phone:

Education
Name Of School:
City/Town:
Grade:
Guidance Counselor:
Extra-Curricular Activities:
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Is volunteering a school or religious requirement? — Yes No
If yes, please state hours required:

If no, why are you interested in volunteering?


Languages
What Languages Do You Speak?

Volunteer Preferences
Patient Care Services — Yes No
Office Services — Yes No

References
Guidance counselor must fill out the Sponsor Evaluation Form and return it by mail in a school envelope to:

Denise Whitley
Coordinator of Volunteer Services
7600 River Road
North Bergen, NJ 07047
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Availability
Please note hours available in appropriate spaces.
(Actual commitment time will be determined during interview with the Coordinator of Volunteer Services.)
Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:

I agree to abide by the requirements and regulations of Palisades Medical Center and the service to which I am assigned. I will serve a minimum of sixty hours (60) after participating in required training. Letters of recommendation or acknowledgement of Volunteer Service will not be issued prior to completion of 60 hours of volunteer service.

Retype Full Name For Signature:
Date:

Parent/Guardian Agreement
My son/daughter is 15 years of age or older, has successfully completed the first year of high school, and has my permission to volunteer at Palisades Medical Center. I realize the responsibilities of this position and will cooperate to help him/her to comply.

I authorize Palisades Medical Center and the Palisades Medical Center Foundation to use my son's/daughter's name and/or photograph in marketing materials to help promote Volunteer Services at Palisades Medical Center.
Yes No

In the event that my child becomes ill or injured while volunteering and I cannot be reached, I hereby give my consent to have him/her treated by a staff physician.

Retype Parent/Guardian Full Name For Signature:
Date: