Susquehanna Health VolunTEEN Services Application Form

Please complete all of the information requested on the application.
All fields in red must be completed.

Personal Information
  First Name
  Last Name
  Age
Month
 Day
 Year
  Phone
  Cell Phone
  E-Mail Address

Address
  Street/Apt/Box
  City
  State
  Zip

Parents/Guardians
  Name of Parent(s)/Guardian(s)
  Address
  City
  Zip
  Home Phone
  Work Phone


  Name of Parent(s)/Guardian(s)
  Address
  City
  State
  Home Phone
  Work Phone

Education
  School
  Grade
  Name of Guidance Counselor
  Extracurricular Activities

Volunteer Interests
  Why do you want to be a VolunTEEN
  Skills and/or Hobbies
  Campus preference Muncy Williamsport or Divine

Please read and acknowledge the following statement.

I authorize investigation of all statements contained in this application; I understand that misrepresentation of omission of facts called for is sufficient cause for dismissal. In addition, I authorize SH to perform the required PPD tests for tuberculosis. Cost is covered by SH.)

I hereby acknowledge that I have read the above statements, understand them and agree with them.