The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

WezKrqFka49hiJM3SqqhNzPzptDsgaIUbDRapsfByawf9qMWGPCd3aGgqM6TYVbHeqJTekCyic3y8q

Youth Advisory Council Application 2017

Thank you for your interest in the Youth Advisory Council! Please click on the link to complete your application. Please contact the Child Life and Education Department at (501) 364-1412 if you have questions about the application process.

Once your application is complete, you will receive a link to submit a parental consent form and identify references. In addition to this, you must have a minimum of two (2) references to complete your application packet--incomplete packets will not be considered. Deadline for applications is May 15, 2017.

YAC Application Process:

1) Complete application
2) Have guardian complete parental consent form and upload or mail it in
3) Identify three (3) references-- teacher/school administrator, employer, minister or an ACH staff member (physician, nurse, other staff member).
4) ACH will process and review applications
5) Phone interview
4) If chosen as a YAC Member, you will be asked to complete additional paperwork and health requirements

Meetings are held on the 3rd Monday of each month from 6:00-7:30pm.

Name (first, middle, last):

* must provide value

Date of Birth:

* must provide value

M-D-Y

Social Security Number (ex. 123-45-6789):

* must provide value

Relationship with ACH:

* must provide value

Patient

Sibling

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Street Address

* must provide value

City:

* must provide value

State:

* must provide value

Zip Code:

* must provide value

Home phone:

Cell phone:

* must provide value

Email:

*All time-sensitive communication sent via email to YAC members will also be sent to parent/guardian as well.*

* must provide value

I prefer to be contacted by:

* must provide value

Home phone

Cell phone

Name of school attending:

* must provide value

Grade during the 2016-2017 school year:

* must provide value

9th

10th

11th

12th

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Interests / Hobbies / Extracurricular Activities

* must provide value

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What special skills, training or talents do you bring to the Youth Advisory Council?

* must provide value

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Reason why you or your sibling(s) come to Arkansas Children's Hospital:

* must provide value

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What care services have you or your sibling(s) used? (check all that apply; your health information will remain confidential)

* must provide value

Adolescent Medicine ï¯

Allergy/Immunology

Blood Disorders

Burn

Cancer

Cardiology

CVICU

Ear Nose and Throat

Emergency Department ï¯

Endocrinology/Diabetes

Eye

Gastroenterology/GI ï¯

General Pediatrics

Genetics/ Birth Defects

Infectious Disease

Neonatal Intensive Care Unit (NICU)

Nephrology/Kidney

Neurology

Orthopedic

Pediatric Intensive Care Unit (PICU)

Pulmonary ï¯

Rehabilitation

Surgery

Transplant

Urology

What do you like about Arkansas Children's Hospital?

* must provide value

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What do you want to get out of your involvement in the Youth Advisory Council?

* must provide value

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Describe your perfect teen hospital. How would you make these ideas happen at Arkansas Children's Hospital?

* must provide value

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Is there anything else you would like to share?

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Primary Emergency Contact Name:

* must provide value

Relationship to applicant:

* must provide value

Phone Number:

* must provide value

Email:

* must provide value

Secondary Emergency Contact Name:

* must provide value

Relationship to applicant:

* must provide value

Phone Number:

* must provide value

I will attend all meetings.

* must provide value

Yes

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I am willing to attend special events and help with scheduled volunteer opportunities.

* must provide value

Yes

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I agree to have any medical tests and immunizations (example: 2 step-TB skin test and flu shot) as required by Arkansas Children's Hospital.

* must provide value

Yes

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I certify that the statements made in this application are true and complete.

* must provide value

Yes

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Please print off the attached document, have it signed by your parent or guardian and upload the completed document.

You will receive a link which allow you to upload the document and identify references.

Attachment:YAC PARENTAL CONSENT FORM.pdf

Please read carefully. For your application to be considered, you must sign and date this form in the spaces below.
I hereby apply to the Arkansas Children's Hospital for volunteer assignments, and, if accepted, I agree to keep all rules and regulations and perform all duties assigned to me to the best of my ability according to the prescribed philosophy of the hospital.

I understand and agree that if I become a volunteer, I will be a volunteer "at will." In volunteering either the hospital or I may end the relationship at any time for any reason. No representative of the hospital has the authority to vary this arrangement. I also agree that nothing in the hospital's policies, rules, regulations or handbook changes this relationship, nor may it be construed as a contract of employment.

Electronic Signature:

* must provide value

Date:

* must provide value

M-D-Y

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