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JUNIOR VOLUNTEER APPLICATION

Personal Information:

Name:
Address:
City:	State	Zip
Home Phone	Mobile	Other
SSN
School Attending:		DOB
Grade Next Year:		GPA
Community Activities
How did You learn about the Junior Volunteer program?

Please list past volunteer experience - include dates.

Service Opportunities

	Nursing Aide	Assist nursing staff and unit receptionists with daily tasks. Provides non-medical assistance with patients and patient visitiation.
	Department Aide	Assist departments with admission procedures, patient transports, clerical assignments, etc.

You will be required to purchase at UT Medical Center Junior Volunteer shirt to wear while you are performing your volunteer service. The cost of the shirt is $15.00. Money will be collected at orientation. Please indicate what size shirt you will need.

	X-Small
	Small
	Medium
	Large
	X-Large

In case of an emergency contact:

Name:
Relation to You:
Home Phone:		Other:

References
Please provide complete mailing address for your references. Incomplete applications will not be processed. Personal Reference -Teacher or Adult friend that you have known for at least one year.

Name:
Address:
City:	State:	Zip:

Medical Reference - Primary care physician

Name:
Address:
City:	State:	Zip:

Are you currently suffering from any condition that might limit your service, or of which we should be aware?

	Yes
	No

If Yes, please explain:

In order to complete your registration, please print and complete forms below

Medical Release form needs to be downloaded. (PDF)
Parent permission form needs to be downloaded. (PDF)

Both need to be printed and signed.

The University of Tennessee Medical Center | 1924 Alcoa Highway Knoxville, Tennessee 37920-6969 | Telephone: 1.865.305.9000.
To make an appointment, call 1.877.UT.CARES (1.877.882.2737) Privacy | SiteMap | Employee Access

The University of Tennessee Medical Center provides medical treatment without regard to disability, age, race, color, religion, sex or national origin.