Teen Pet Volunteer App

Please select the Jackson facility where you wish to apply.

* First name

* Family/last name

* DOB

* Address

* Line 2

* City

* State

* Zip/postal

* Phone (Mobile)

Phone (Home)

* E-mail

* Social Security Number * last 4 digits?

Additional languages you speak fluently (select all that apply)

Have you lived in Florida for the past seven (7) years?

Present/Former Employer

Position Held

Work Experience

Volunteer Experience

Length of Service

Reason for Leaving

* Why did you choose to volunteer at Jackson Health System?

Placement Preferred

Availability

Sunday

8am-Noon

Noon-4pm

4pm-8pm

Monday

8am-Noon

Noon-4pm

4pm-8pm

Tuesday

8am-Noon

Noon-4pm

4pm-8pm

Wednesday

8am-Noon

Noon-4pm

4pm-8pm

Thursday

8am-Noon

Noon-4pm

4pm-8pm

Friday

8am-Noon

Noon-4pm

4pm-8pm

Saturday

8am-Noon

Noon-4pm

4pm-8pm

* Emergency contact

* Relationship to you

* Name of School

* Phone (Mobile)

School Program (if applicable)

School Contact (Teacher/Counselor)

* Highest Grade Completed

* Please list your Hobbies/Skills

Can you meet the 150 hour requirement?

How did you hear about Jackson Health System?

Are you affiliated with any community organization?

If so, please select the community Program you are affiliated with

Please enter names of two (2) personal contacts NOT related to you. Please note you will be asked to submit a letter of reference.

* Reference 1

* Reference 2

Have you ever volunteered at Jackson Health System?

Do you have any relatives presently employed by Jackson Health System/PHT?

If yes, please list name(s) and department(s)

Pet Therapy Questions

* Name of Pet

* Breed of Canine

* Canine Date of Birth

* Most recent veterinary assessment

Which Pet Therapy Certification Agency are you affiliated with?

* Please upload the certification from the Pet Therapy Agency

I agree to abide by the policy/rules set forth by the Public Health Trust and the Volunteer Resources Department at Jackson Health System. I will attend orientation, complete Health Office requirements and all necessary training. I will observe the Volunteer Dress Code, Code of Ethics and agree to keep all patient information confidential. I understand that I will not be paid for my volunteer services. I understand that failure to abide by the above mentioned are grounds for inmediate dismissal.

I authorize investigation of all statements herein and release Jackson Health System/Public Health Trust for liability in connection with same. I also understand that false, misleading or omitted information herein may result in dismissal regardless of the time of discovery by Jackson Health System/Public Health Trust.

Teen typed signature