Volunteer Services Department

Teen Volunteer Profile Form

732-937-8507

Name: __________________________________________________________ Date: _____________

Last First MI

Address: ___________________________________________________________________________
Street Town State Zip

Cell #: _______________________ E-mail: _____________________________________________

Date of Birth: ____/____/____ Gender: Female__ Male__ Non-Binary__ Prefer not to respond__
MM DD YY

High School: _____________________________________________________ Grade: __________

Guidance Counselor Name: ________________________________ Graduation Year: _________

Reference: (Adult non-family - teacher, clergy, employer, coach, or neighbor)

Name: _______________________________ Relationship: _______________________________

Mailing or E-mail Address: ___________________________________________________________

Employment Experience: _____________________________________________________________

Volunteer Experience: _______________________________________________________________

Why are you interested in volunteering at RWJUH? ______________________________________

___________________________________________________________________________________

Availability: (please check all that apply)

Weekday - M____ Tu____ W____ Th____ F____ Time - 4-6pm____ 6-8pm____
Weekend - Saturday____ Sunday____ Time - Morning____ Afternoon____ Evening____

This application must be filled out by the prospective volunteer, signed, and returned to
[email protected] OR One Robert Wood Johnson Place, New
Brunswick, NJ 08901.

Please complete both sides!

1
 Volunteer Services Department
Teen Volunteer Profile Form
732-937-8507

I certify that the above information is correct and complete and I authorize RWJUH and its affiliated entities to
investigate any statements that I have made. I understand any false statement on this application may be
considered for rejection of this application or immediate termination if my volunteer assignment has begun. I
acknowledge that completing this application and interview/screening process is not a promise of an assignment
offer. I agree that once accepted into the Teen Volunteer program I will commit to serve a minimum of two hours
each week. I understand a minimum of 1 year of service AND 100 hours is required and that no verifying
documentation will be given until this minimum is met.

Signature: _________________________________________ Date: ______________________

Teen Applicant

I permit my child to volunteer at RWJUH serving a minimum of two hours each week. I understand a minimum of
1 year of service AND 100 hours is required and that no verifying documentation will be given until this minimum
is met. I assume responsibility for their transportation, understand the duties involved, and will support my child in
their volunteer efforts. I also grant permission for my child to be photographed and/or interviewed for various
publications, media releases, displays, etc. as needed for RWJBarnabas Health functions.

Signature: ________________________________ Primary Contact #: ______________________

Parent/Guardian

Print Name: ________________________________ E-mail: _______________________________

FOR VOLUNTEER DEPARTMENT USE ONLY

Reference Forms Sent: ______________________ Returned (G)_________________ 1. _____________________

Medical Form: _____ TB Clearance: _____________ Immunizations: _____________________

Orientation Packet Returned _______ Photo ID _______________________

Notes: _________________________________________________________________________________________

Interview Date: ______________________ By _________________ NVO _____________________ NB

Placement: _______________________________________________ Start Date: __________________________

Department Day Time

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 Guidance Counselor
Confidential Evaluation
1 Robert Wood Johnson Place
New Brunswick, NJ 08901
ATTN: Volunteer Services

Student’s Name: ____________________________________________________________________

School Name: ________________________________________________ Grade: ___________
CONSENT TO RELEASE SCHOOL RECORDS
I authorize a representative of the above school to complete the School Guidance Counselor
Evaluation Form in connection with the above student’s application to participate in the Teen
Volunteer Program at Robert Wood Johnson University Hospital. I understand the purpose of
this form is to aid RWJUH in selecting qualified student volunteers.
All information provided by the school will remain confidential.

Parent/Guardian Signature: ________________________________________ Date: ___________

DO NOT WRITE BELOW THIS LINE - TO BE COMPLETED BY GUIDANCE COUNSELOR
I would rate this student as follows:

1. Requires (less/more/about the same) amount of instruction as most students.

2. Requires (minimal/occasional/considerable) amount of supervision or direction.
3. (Does/Does not) follow through on assignments.
4. Gets along (very well/well/not well) with peers.
5. Gets along (very well/well/not well) with adults/staff.
6. (Has/Does not have) adequate emotional maturity to work with hospital patients.
7. (Is/Is not) regular in school attendance. If not, what is the cause of absence or tardiness?
_______________________________________________________________________________

___________ I recommend this candidate to be accepted to the Teen Volunteer program at

VVVVVVVVVV Robert Wood Johnson University Hospital.

___________ I do not recommend this candidate to be accepted to the Teen Volunteer

VVVVVVVVVV program at Robert Wood Johnson University Hospital.

Comments: _______________________________________________________________________
__________________________________________________________________________________
Signed: ______________________________________________________ Date: _______________
Print Name & Title: _________________________________________________________________

Please return to the Volunteer Services Department

via fax 732-418-8238 or the address above. Form can also be emailed to
[email protected] Thank you.

RWJUH Volunteer Services Department TEL: 732-937-8507

Volunteer Services Department

To Whom It May Concern:

_________________________________ has applied for volunteer service at Robert Wood Johnson

University Hospital. Please complete this form as a reference. Your candid responses to the questions
below are appreciated and will be kept confidential. Your prompt consideration will allow me to process
the application in a timely manner.

Thank you in advance for your assistance.

Sincerely,
Jacob Persily
Director, Volunteer Services

How long have you known the applicant? _________________________________________________

In what capacity do you know the applicant? ______________________________________________
What can you share about the applicant’s skills and abilities? _________________________________
___________________________________________________________________________________
What can you share regarding the applicant’s character and personality? _______________________
___________________________________________________________________________________

Would you recommend the applicant as a volunteer for our program? _________________________

Please share any additional comments you think we be helpful in the placement of this applicant
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_______________________________________ ______________________________
Signature Phone Number

________________________________________ _________________________________
Print Name Date

Please contact the Volunteer Services Department at 732-937-8507 with any questions.
Completed reference letters can be returned to the address listed below, scanned and emailed to
[email protected], or faxed to 732-418-8238.

One Robert Wood Johnson Place

New Brunswick, NJ 08901
732-937-8507
 Attachment #1 Volunteer Application Medical Clearance Checklist
Name: Phone Number:

ADULT (18 y/o or older) OR TEEN (17 y/o or younger): Date of Birth:
Email:
Department: VOLUNTEER SERVICES / RESOURCES Social Security #:

For Medical Professional (MD, DO, APN, PA)

Task Notes
By PCP with vaccine and titer documentation
 Physical exam within past 12 months
attached
TB blood or two skin tests (e.g. QFTG,
QFTplus4T, or TSPOT) collected within the
 Tuberculosis (TB) screening via blood or two skin tests
past 3 months (documentation must be
attached – see attachment #2)

 Proof of immunity to all the following viruses: Documentation must be attached

 Rubella (German Measles) A positive IgG titer or proof of 1 MMR vaccine

A positive IgG titer or proof of 2 MMR
 Rubeola (Measles)
vaccines, given > 4 weeks apart
A positive IgG titer or proof of 2 MMR
 Mumps
vaccines, given > 4 weeks apart
A positive IgG titer or 2 VARIVAX vaccines,
 Varicella (Chicken Pox)
given > 4 weeks apart
A positive hepatitis B surface Antibody titer
BLOOD TEST for immunity (HepBsAb); If
 Hepatitis B (Blood test required regardless of
negative (not immune), then either a
vaccination status)
Hepatitis B vaccine series started or a signed
declination form at your final appointment.
Must be the ADULT version of the vaccine –
 Proof of vaccine for TDaP (Tetanus, Diphtheria,
Adacel or Boostrix. (The childhood DTAP is
pertussis)
not acceptable).
 Proof of Influenza (Flu) vaccine Flu season only: Approx. Sept – April
For Volunteer Applicants:

If you are 17 or younger, you must be

Ensure both pages of the medical attestation forms are
 accompanied by a parent or legal guardian
completed by your provider, and signed/dated.
with their valid photo ID.

Call Employee Health to make your

Make your appointment with Employee Health to submit
appointment. Please do not send any medical
 your Medical Attestation form, vaccination
forms or paperwork to the Volunteer
documentation, and blood test results
Department.
All appointments must be no later than 2 PM,
You will be cleared to volunteer after submitting all
Monday-Friday, to accommodate the drug
 requisite medical information above and completing a
screening process.
urine drug screening at your appointment.

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Attachment #2 Tuberculosis (TB) Screening/Respiratory Assessment: ALL must complete Parts A, B, C

NAME:___________________________________________________________________DOB_____________Dept: Volunteer

A. RISK assessment:

1. Do you have any history of a Positive Tuberculosis Test (Skin (PPD/TST) or Blood)?_________
If Yes: When was your FIRST Positive TB test? ___________. Do you have proof? _______
Did you take a complete course of medication for TB (usually 4 - 12 months)? ______
If yes, what did you take?_______________________, for how many months?______

2. Have you lived in another Country?______ Where?:________________How many years?_______

3. Are you currently Immune Suppressed? _______ If yes, how?_________________

4. Have you had prolonged close contact with someone with Tuberculosis? __________

B. SYMPTOM evaluation: Do you have any of these symptoms of contagious TB? Circle Yes or No
1. Fever / Chills- Yes / No
2. Loss of appetite- Yes / No
3. Coughing up blood- Yes / No
4. Unexplained Weight Loss- Yes / No
5. Tires easily (without a reason)- Yes / No
6. Night Sweats (other than menopause)- Yes / No
7. Coughing frequently for greater than 3 weeks- Yes / No

Volunteer SIGNATURE: ___________________________________________ DATE:__________

C. TB Testing (must be with in past 3 months):

TB Blood test: (QFTG/QFTplus4T/TSPOT) Date Collected- ___________ Result: _____________

OR
TB Skin test: (2 Step PPD/TST tuberculosis test):

PPD#1: Date plant- _____________ Date read- ____________ Reading (mm) _____

PPD#2: Date plant- _____________ Date read- ____________ Reading (mm) _____

D. Respiratory Assessment: Required for Positive Symptoms or Positive TB test (or history of positive test).

1. CXR (PA, w/in 1 year) Date:__________ Result:______________

2. TB blood test (if not already done): Date:__________ Result: ____________

3. Exam: Coughing:______ Temp:______ BMI: _______ Lung Exam (Spec Atten Upper Lobes):__________

I attest the above-named Individual has completed ALL medical requirements listed above in Attachments I and II, is
free of communicable disease, and if any of their viral antibodies are negative/equivocal, they are currently compliant
with the associated vaccine series schedule. All documentation is retained in my Medical Facility and will be provided if
requested.

Medical Provider: __________________________________________ ___________________________ __________

(MD, DO, APN, PA) PRINT Name, Title Sign Date

Phone#:______________________ License#___________________ Address:_________________________

-----------------------------------------------------------------------------------------------------------------------------------------------------------
RWJBH Employee Health Only:
Reviewed by:________________________________ TB Risk category:_________ ENTER into AGILITY: ____________

Page 8 of 12
Attachment #5: New Volunteer- Consent and Authorization to Treat Form.

Name (Please Print): __________________________________________ Date of Birth: ____________

o I hereby give my consent for diagnostic testing and a physical examination to evaluate my suitability for Volunteering within
RWJBH. I understand that this exam and subsequent exams are to determine my Volunteer placement and continued Volunteer
status and not intended to take the place of personal medical care. Additionally, these tests/exams should not be considered
complete health assessments; for that I must contact my personal physician.
o I further consent to diagnostic testing, exam, and/or treatment for any injury or illness that occurs in relationship to my
Volunteering, or for any other conditions for which I seek care in the Corporate Care/Employee Health Department.
o I understand that my medical records will be maintained in a confidential manner. If I transfer to an alternate site within
RWJBH, I agree that my Volunteer medical records may be transferred to the Corporate Care/Employee Health Department
responsible for the site at which I am Volunteering.
o My responses to any Volunteer Medical History Record Questionnaire will be used to evaluate suitability for Volunteering
and/or whether a reasonable accommodation for any disability will be needed.
o I understand that it is important to provide all medical information to the best of my knowledge. If there is information I am
uncertain of in this Volunteer application to this request, I must discuss it with a representative from Corporate Care/Employee
Health Department. Omitting information or providing false information on the medical history form is grounds for
withdrawal or termination of Volunteer assignments.
o The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family
medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's
family member sought or received genetic services, and genetic information of a fetus carried by an individual or an
individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.

_________________________________________________________________ _______________________

Volunteer Signature Date

--------------------------------------------------------------------------------------------------------------------------------------------
For MINORS (Less than 18 years old; e.g. anyone who is 14-17 years old):

_________________________________________ __________________________________ ___________

Parent/Guardian Signature Parent/Guardian Printed Name Date

___________________________________ ____________________

Witness Signature Date

----------------------------------------------------------------------------------------------------------------

( ) I have received and read this Consent and Authorization to Treat Form and do NOT provide consent for diagnostic testing,
examination, treatment; as a result, I understand my Volunteer Application may be denied.

___________________________________________________ _________________

Volunteer or Parent/Guardian Signature Date

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