Your Name Date of Birth Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Phone Number Email Parent's / Guardian's Name Parent / Guardian Phone In which areas of the hospital have you been seen? (Check all that apply) Inpatient Floors Ambulatory Procedure Center (APC) Radiology SLCH Outpatient Clinics Pediatric Acute Wound Service Same Day Surgery Emergency Unit Children’s Specialty Care Center Therapy Services Dialysis Center How much time are you able to commit to the Teen Life Council? (Check all that apply) 2 hours a month for scheduled meetings Additional teen focused hospital events 1-2 times a month Weekly commitment requiring hospital volunteer orientation None of the above Please tell us about your experiences with St. Louis Children’s Hospital or any important medical experiences. Why are you interested in becoming a Teen Life Council Member? How did you hear about our program: Teen Life Council Brochure Child Life Specialist Other Staff Member Social Media St. Louis Children's Hospital Website Other Other (optional) By checking this box, I verify the above information to be current and accurate, and it serves as my signature. By checking this box, I confirm that I have my Parent/Guardian’s permission to apply (if applicant under 18)
Your Name Date of Birth Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Phone Number Email Parent's / Guardian's Name Parent / Guardian Phone In which areas of the hospital have you been seen? (Check all that apply) Inpatient Floors Ambulatory Procedure Center (APC) Radiology SLCH Outpatient Clinics Pediatric Acute Wound Service Same Day Surgery Emergency Unit Children’s Specialty Care Center Therapy Services Dialysis Center How much time are you able to commit to the Teen Life Council? (Check all that apply) 2 hours a month for scheduled meetings Additional teen focused hospital events 1-2 times a month Weekly commitment requiring hospital volunteer orientation None of the above Please tell us about your experiences with St. Louis Children’s Hospital or any important medical experiences. Why are you interested in becoming a Teen Life Council Member? How did you hear about our program: Teen Life Council Brochure Child Life Specialist Other Staff Member Social Media St. Louis Children's Hospital Website Other Other (optional) By checking this box, I verify the above information to be current and accurate, and it serves as my signature. By checking this box, I confirm that I have my Parent/Guardian’s permission to apply (if applicant under 18)
