Sara Forman Hart Volunteer Suite

Vassar Brothers Medical Center

45 Reade Place
Poughkeepsie, New York 12601











Picture Yourself a VBMC Volunteer!
Dear Student,

What does your future hold? The answer to this question is entirely up to you. Everything that
you do from this point on is a stepping stone to the person you will become. There is a world of
opportunity just waiting for you!

As you make the decisions that will shape your life, Vassar Brothers Medical Center is here to
help you. Volunteering at VBMC will:
provide valuable experience that will help you to get into the college of your choice;
give you exposure to the vast career opportunities in the exciting field of health care;
be a fun, rewarding experience and an opportunity to meet new friends.

How to Apply:
Fill out the attached application form
Have the enclosed medical information forms completed by your physician
Be sure to get all required signatures:
o Parental consent
o Guidance Counselor recommendation
o Physicians signature
Mail to:
Sara Forman Hart Volunteer Suite
Vassar Brothers Medical Center
45 Reade Place
Poughkeepsie, New York 12601

Once we receive your application:
An appointment will be made for you to meet with our Employee Health Nurse
You will be interviewed by the Volunteer Supervisor
If accepted into the program, you will be notified about orientation date

We require that all VBMC Student Volunteers:
Complete a minimum of 50 hours of service
Wear the required VBMC Student Volunteer uniform and name badge at all times during
service hours (order form enclosed)
Abide by the policies and procedures of the VBMC Volunteer Department

Summer Volunteer Patient Care Assistant Program
We encourage those who are already considering a career in health care to join our Volunteer
Patient Care Assistant Program. This program, which requires an additional 8 hours of
training, will enable you to work alongside the patient-care staff helping to meet the needs of our
patients. You will become a valuable member of our health care team, and know the satisfaction
that can only come from making another person happy. To be a member of this elite team you
will need to:
Attend an 8-hour mandatory training program
Commit to an average of 8 hours of service each week during your summer vacation

We look forward to meeting you! Please feel free to call us with any questions.

Tara Marquis
Manager, Volunteer Resources
845-431-5664
tmarquis@health-quest.org





Dear Parent/Guardian:

Thank you for allowing your child to participate in the Student Volunteer Program
at Vassar Brothers Medical Center. We are sure that the experience will be not
only beneficial to them, but enjoyable as well.

The New York State Department of Health requires that all employees and
volunteers be given physicals and prove immunity to certain diseases. Please ask
your childs health care provider to:
Complete the enclosed health history form
Provide your childs immunization record
Provide signature where indicated


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Consent for Necessary Medical Procedures

I hereby give permission to physicians and/or medical staff of Vassar Brothers Medical Center to
render procedures (blood tests, skin test and/or chest x-ray) deemed necessary for the proper
testing of hospital employees and volunteers as required by New York State Department of
Health regulations.

PPD (Tuberculin) skin testing (or chest x-ray, if applicable)
Rubella (German Measles) blood test
Rubeola (Measles) blood test
Varicella (Chicken Pox) blood test


Parent/Guardian consent: ______________________________________________________



Volunteer Signature:___________________________________________________________



Date:_______________________________________________________________________







Dear Doctor:

__________________________________________________ has applied for a Volunteer assignment at Vassar Brothers
Hospital and has listed you as their health provider. This volunteer may be assigned to work directly with patients,
therefore as part of the application process, it is important for us to evaluate the individuals health status. Would you
please complete the brief form below and return it to the applicant. Thank you for your input.
Allison Tebolt, Nurse Practioner
Employee Health Services



I, ____________________________________________ give permission for release of the requested
information.

___________________________________________ _______________________________
Applicant or guardians signature Date

Has the applicant any physical or mental disability about which we should be aware before making our assignment? Or
that might prohibit him/her from volunteering in the hospital? No____ Yes ______ If yes, please explain on reverse
side of form.


Physician Signature _________________________________ Date: ___________________

Please complete below, if known


PPD (Mantoux Tuberculin Skin Test).Date:____________________ Results: __________

Two (2) Rubeola Vaccines or 2 MMR vaccines since first birthday if born after 1/1/57.

Date: _________________ Date: __________________ DOB: _______________________

or Rubeola Titre Date __________________________ Results: _______________

Rubella Titre date: _____________ Results: ____________ All volunteers regardless of age must show
immunity to Rubella (Will be done in Employee Health if results not available).

Hepatitis B Vaccine :#1 _____________________
(dates)
#2 _____________________

#3 _____________________


Tetanus Date : __________________


Varicella History _________

Varicella Titre Positive Date: _____ _______

Varivax #1__________________________

#2 _________________________

VB 50291 Rev. 10/07

HEALTH HISTORY

NAME: MALE
FEMALE
Date of Birth Age
HOME ADDRESS CITY
STATE
ZIP
HOME TELEPHONE Notify in Case of Emergency:
Relationship: Telephone:
DEPARTMENT POSITION SHIFT
HEALTH HISTORY
In order to assist the healthcare provider to determine your ability to perform the essential functions of the job or the need for reasonable
accommodations, please complete the following about your health history:

Have you had any of the following? Check
Yes( ) or NO ( ). If Yes, indicate year(s)
of occurrence
YES NO YEAR Have you had any of the following?
Check Yes or NO. If Yes, indicate
year(s) of occurrence
YES NO YEAR
Any skin or other health-related condition
which causes irritated skin or open lesions
Stomach Disorder (ulcer, GERD)
Mouth or Dental Problems Bowel or Rectal Disorder (frequent
diarrhea, chronic constipation)

Hearing loss or problems Kidney or Bladder Disease
Vision problems (color blindness, cataract,
glaucoma, other)
Diabetes
Severe Headaches Thyroid Disease
Difficulty breathing (asthma, chronic
bronchitis, emphysema, shortness of breath,
chronic cough)
Tuberculosis
Neurological Disorder
Heart Condition, murmur, heart attack,
Rheumatic Fever
Seizure disorder (epilepsy or other)


High Blood Pressure Hernia
Anemia, blood disorder Hepatitis or Liver disease
Cancer Mental Illness or breakdown
Have you been hospitalized in last 2 years Have you been treated for substance abuse
or addiction

Have you had an injury, recurring pain, limited motion or surgery associated with:
Neck Back
Shoulder Knee/Ankle
Arm/Wrist/Hand Other

Do you smoke now? NO YES

If yes, how much?________ If you stopped smoking
completely, how many years ago? _______
Do you drink alcohol? Yes No

If yes, how many drinks per week ______
per month? ______
Rarely ________


Have you had any surgeries, or any other health conditions, please list:
__________________________________________________________________________________________
__________________________________________________________________________________________
Comments:



ALLERGIES:

2. List all medication allergies and type of reaction:
______________________________________________________________________________________________________

Do you have other allergies, please list:______________________________________________________________________

Are you allergic or sensitive to LATEX (natural rubber): YES NO


Has your Mother, Father,
Sister, or Brother had a history
of:


Yes


No


relationship


Name of personal
physician/provider:______________________________

Address:
Tuberculosis
Diabetes Females:
Last Menstrual Period: ________

Last Gyn Exam :_______________

Are you pregnant Yes
No
Males:

Last testicular
exam:________

Last prostate exam:
________
High Blood Pressure
Heart Disease
Mental Illness
Cancer

Comments:
_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________
MEDICATIONS

4. Do you take any medications on a regular basis? Yes No If yes, please list: ________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
5. Do you have any other medical condition(s) we should know about in case of a medical emergency? Yes No If yes, please describe:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
HISTORY IMMUNIZATIONS/COMMUNICABLE DISEASE

6. Please check () and list date(s) for the following communicable diseases and/or immunizations and TB skin tests:
And please submit any available documentation.
TYPE Yes No Vaccine DATES
Tuberculin Skin Test:

Last date: __________ negative
positive

Last Chest x-ray __________________

(Applicants with a positive history must complete
an additional questionnaire)
Chicken Pox
Rubella (German Measles)
Measles
Mumps
Hepatitis B
Tetanus


All employees are required to have Tetanus Diphtheria Vaccine unless
immunized within the past 10 years.


I certify that the above information is correct to the best of my knowledge and recollection, and I hereby authorize Vassar Brothers
Medical Center to investigate all statements given herein. If found false, I agree that this will constitute sufficient grounds for
termination of employment. In addition, I also give my permission for a medical examination as required by VBMC, and for
immunizations and laboratory testing required by the New York State Health Code and Hospital Policy for Hospital Employees. This
and other medical information will be held in strict confidence. It will be released only where required by law. Non-confidential
information regarding work restricitions relating to job assignment will be provided to management and personnel.
Signature of Applicant: _______________________________________________Date:_____________________


Reviewed by Health Provider (Signature):________________________________________________________________________ H&P: Vol 4-03

Sara Forman Hart Volunteer Suite 45 Reade Place Poughkeepsie NY 12601 845-431-5664
STUDENT VOLUNTEER APPLICATION FORM
PERSONAL
Last Name First
Middle

Date of Birth


Street Address Apt. No. Telephone Number
Home: ( )
Cell: ( )
E-Mail Address:
City State Zip Code

Parent/Guardian Name: Daytime Phone: Evening Phone:

Emergency Contact (If Different From Above): Relationship:

EDUCATION INFORMATION
School What Year Will You Graduate?

Address Telephone
Guidance Counselor
Educational Goals:

YOUR INTEREST:
Patient Care Outpatient Registration Guest Services/Information Desk Gift Shop
Clerical Assignments Flower Delivery Patient Transportation Fishkill Amb/Surg Center
Food & Nutrition Cancer Center Same Day Surgery Graphic Arts
Library Cart

AVAILABILITY:
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
8:30 12:30
MORNING

12:30 4:30
AFTERNOON

4:30 7:00
EVENING


APPLICABLE SKILLS/TALENTS/INTERESTS:
Fluency in another language , including sign language (Please specify):________________________________
Photography Art (ie: painting/crafts) Other (Please specify):________________________________

STATEMENT OF APPLICATION
The above statements are true and all information and reference given on this application may be investigated without liability of
Vassar Brothers Medical Center. If accepted to participate in the Program, I agree to abide by the policies of the Volunteer
Department of Vassar Brothers Medical Center. I understand that if any of the statements in this application are found to be untrue,
or I fail to comply with all stated requirements, I may be subject to immediate dismissal from the Vassar Brothers Medical Center
Volunteer Program.

SIGNATURE: ____________________________________________________________

****Please complete information on reverse side!****
REQUIREMENTS FOR STUDENT VOLUNTEERS

Age: 16-18 years
Parent/Guardian consent
Parent/Guardian permission for required medical information and tests
Recommendation of Guidance Counselor
Medical reference completed by physician
Physical with VBMC Employee Health Nurse
Personal interview with VBMC Volunteer Coordinator

Parent/Guardian Signature:_____________________________

Guidance Counselor Signature:__________________________ High School:_________________________


CONFIDENTIALITY STATEMENT

It is the responsibility of Vassar Brothers Medical Center and all of its physicians, employees, and volunteers to
protect the confidentiality of the medical records and privacy of all patients. The patient has a legal right to
privacy concerning his/her medical record. It is the obligation of the Medical Center to uphold that right. For
this reason, no member of the hospital to whom medical records or patient information is available may in any
way violate this confidentiality. You are expected to hold all information about patients and their families in
strict confidence and not discuss patient information with other volunteers or with other persons outside of the
hospital. Persons found to be in violation of this policy will be subject to sanctions.

I have read the above statement and agree to abide by it wholeheartedly.

Volunteer: Date:

PHOTOGRAPHY / VIDEOGRAPHY CONSENT FORM

I hereby permit and release to Vassar Brothers Medical Center and/or its affiliates the use of pictures taken for
the purpose of recruitment and publicity of the VBMC Volunteer Program.

Parent/Guardian Signature: Date:

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VBMC Student Volunteer Uniform Order Form

The student volunteer uniform consists of a burgundy scrub top and black scrub pants. These uniforms must be
worn, along with the volunteer name badge, during the entire course of duty at VBMC. A plain white t-shirt
may be worn under the scrub top.

Please circle the appropriate size (remember, they are unisex) and enclose a check or money order for $25.00
made payable to Vassar Brothers Medical Center.

X-Small Small Medium Large X-Large XX-Large