FCCC High School Volunteer Application Form

* First name

M.I.

* Family/Last name

Gender

Preferred Nickname

* DOB

All volunteers must be 15 years old to volunteer at Fox Chase Cancer Center. We invite you to apply again next year! If you believe you have received this message in error, please double check your date of birth and contact us.

Mobile phone

Address

* City

* State

* Zip/postal

* Parent/Guardian's Name

* Parent/Guardian's Email

* Parent/Guardian's Phone (Mobile)

Home phone

Emergency Contact Information

* Contact name

* Relationship

Address

City

State

Zip/Postal

Home phone

* Mobile phone

Work phone

* E-mail (if applicable)

Additional Information

Volunteer source

Primary language

Please list any additional languages

Uniform Size

I am applying as part of the CAPS program (Lower Moreland School District students only)

What type of assignment(s) interest(s) you?

Please indicate any other interests

I have been accepted into a reasearch lab at FCCC

* Lab Contact

* Lab Name

If you know your start date, please enter it here:

Current Year in School

* School

Expected Graduation Date

Available Positions

Summer Volunteer (must commit to at least 8 weeks of volunteering and be available Monday through Friday during normal business hours for a weekly shift). Please check the FCCC website for application deadlines. It is recommended to apply before the end of March.

I am also interested in being a school year volunteer (during the school day volunteers only, please check with your school's counselor, a minimum 1.5 hour commitment and summer volunteering is a prerequiste) NOTE: There are very limited afternoon hours available.

Availability

Monday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Tuesday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Wednesday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Thursday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Friday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

References

Please list two people who would be willing to serve as personal references. The first reference should be one of your teachers, while the second should be a community member (employer, religious leader, volunteer leader, etc.). Neither reference can be a family member.

Reference 1 (teacher)

* Name

* E-mail

Reference 2 (community member, not a family member)

Relationship to Reference 2

* Name

* E-mail

Attestation of Application Answers and Information Provided

I understand that the statements made in my volunteer application are true and correct and have been given voluntarily. I understand that falsification of any information is grounds for dismissal. I voluntarily give TUHS/FCCC the right to make an inquiry of my past experience and I agree to cooperate in such inquiries and release from all liability or responsibility all persons, companies, and corporations supplying such information. I voluntarily give TUHS/FCCC permissoion to contact my references provided above. I understand that I will not be compensated for my services as a volunteer and I am not required to volunteer my services. I understand that acceptance as a volunteer at TUHS/FCCC is contingent upon satisfactory completion of all pre-placement procedures which include but are not limited to orientation, an interview, criminal background investigation(s), completion of HIPAA Certification and completion of required health screenings. I understand that upon my successful completion of the volunteer service on-boarding processes required at TUHS/FCCC and the approval for placement by volunteer Services staff, I will become a volunteer. I agree to abide to the policies of TUHS/FCCC and if I do not, this may result in disciplinary actions. I am aware of and will honor the schedule commitment I make during my interview with Fox Chase Cancer Center Volunteer Services.

* I have read the statement above and I understand and agree.

* Date

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Signature