Volunteen Application - JIRDC Home

J. Iverson Riddle Developmental Center
300 Enola Road • Morganton, North Carolina 28655-4608
Tel 828-433-2731 • Fax (828) 433-2724 • TDD (828) 433-2732
Beverly Eaves Perdue, Governor
Lanier M. Cansler, Secretary
J. Luckey Welsh Jr., FACHE, Division Director
Arthur J. Robarge, Ph.D., M.B.A., Director
February 2012
I know it’s hard to think about what you are going to do for the summer when it’s still winter, but it
will be time for the Volunteen program to kick off before you realize. Since you were a Volunteen last
summer, you get an extra head start in getting your application into Volunteer Services to be included in
the 2012 Volunteen program.
Here are some important dates for you and your parents to mark on your calendars:
• June 11, 2012: Mandatory Volunteen Orientation I, 8 a.m. – 3 p.m. at the JIRDC Chapel
• June 12, 2012: Mandatory Volunteen Orientation II, 8 a.m. – noon at the JIRDC Chapel
• June 13, 2012: In accordance with their fixed schedules, this is the first day that
Volunteens report to their service sites
• July 4, 2012: Independence Day - Volunteens have the day off!
• Aug. 2, 2012: Last day of Volunteens and Volunteen Recognition and Awards Ceremony
Time to be announced later
As you can see orientation is mandatory for all teens, new and returning, and is especially important for
first year Volunteens. You will also have a two-step TB skin test unless you have already had it through
volunteering with us or from your doctor or other healthcare provider. We will need a statement from your
healthcare provider to that effect if the TB test has been done within the past year. Our employee health
nurse will determine if you need another one.
As you already know, the Volunteen program is very competitive and fills up quickly, so be sure to fill out
your attached application with your parents and return to Volunteer Services as quickly as possible. When we
reach our limit, we will stop accepting applications. Please note the attached recommendation form.
I look forward to hearing back from you. Please call or e-mail me with any questions regarding your
application or the Volunteen program.
Sincerely,
Blair Ellis, Volunteer Services Coordinator
828.433.2604
Blair.Ellis@dhhs.nc.gov
A Facility of the
North Carolina Department of Health and Human Services
Division of State Operated Healthcare Facilities
Courier No. 15-07-01

Notes for parents . . .
• As noted in the letter, orientation is mandatory for all teens. It is especially important for new Volunteens.
The information we present in those two sessions is difficult to replicate so it is important that we have
Volunteens on those two days. If there is a question, please call us.
• The Volunteen Program is especially interested in developing an E-Mail list so we can get information to
our Volunteens in an efficient and timely manner. In years past, we have relied on the U.S. Postal Service
and will continue to do so as needed and appropriate. An E-Mail list will allow us to send announcements,
newsletters and other important information that is more immediately available to parents and Volunteens,
plus we can save the State some money on the ever rising costs of postage. We’d love to have “valid” E-
Mail addresses for both teens and parents if possible. The E-Mail addresses should be one that you monitor
on a regular basis. Parents, if you don’t have home internet access, but have a work E-Mail that your
employer let’s you use for occasional personal use, that will be fine as well. We will only use the E-Mail
addresses we get for Volunteen business. If you don’t have internet access or access to E-mail from an
employer, don’t worry, we will continue to send that information to you through the postal service. Oh,
please, and we’re actually begging, write those so we can read them easily. 1’s and l’s look really similar as do
0’s and o’s when they are handwritten.
• Please note that this program runs for eight weeks. If you cannot commit to at least five of the weeks, please
don’t take a spot in the program that could go to someone who can. We generally have somewhere around
40 placements we can make, give or take a couple, and the supervisors we recruit are on-board for the full
eight weeks. We always have people who give us applications after we are full and it is nearly impossible for
us to bring new people into the program once we are in full swing. Please take that into consideration as you
make your plans for the summer.
• We are going to try to setup a Volunteens 2012 Facebook page so be sure to look for that. It will be another
way for us to get information into your hands quickly and efficiently. Again, if you don’t have internet
access at home, we will still send it to you through the mail. Just be sure to indicate that you do not have
internet access at home so we can be sure you will be on a regular mail list.
• If there are ever any questions . . . CALL or E-MAIL me. I have voice mail and I always monitor my E-
Mail. My phone number is 828-433-2604 and my E-Mail is Blair.Ellis@dhhs.nc.gov

J. Iverson Riddle Developmental Center
2012 Volunteen Application
Program Dates: June 11, 2012 - August 2, 2012
Last Name First Name MI Preferred Name
M or F
Mailing Address City State Zip
Birth Date Home Phone E-mail (please write legibly)
A valid E-Mail address is an important tool for us if one is available. It will allow us to give you important information on a timely basis as
well as saving the Center and the State postage costs. It will not be used for any other purpose.
Emergency Contact Information:
Parent and/or Primary Guardian Contact Relationship Home Phone
Address City State Zip
Employer E-Mail Work or Cell Phone
Other Parent or Guardian Relationship Home Phone
Address City State Zip
Employer E-Mail Work or Cell Phone
Additional Emergency Contact Relationship Phone
Please list names and departments of relatives who currently work at the J. Iverson Riddle Developmental
Center: __________________________________________________________________________________
________________________________________________________________________________________
(Volunteens will not be permitted to volunteer in areas or departments where a family member works)
School Information
School currently attended (2011-2012): _________________________________________________
Which school will you attend next year (2012-2013): __________________________________________
What grade will you be in next year (2011-2012): 7 8 9 10 11 12 (please circle one)

General Information About You
Do you already have a firm career interest? If so, what is it?________________________________________
Have you worked with developmentally disabled persons in the past?
_____ Yes ______No
If so, where and when?___________________________________________________________________
Please list other types of service that you have given to your community (where and when):
_________________________________________________________________________________________
_________________________________________________________________________________________
What kind of volunteer work do you want to do at the Center?
No preference ______ Direct contact with residents ______ Indirect contact with residents _____
Check below any skills/training you have had:
______ Word Processing _____ Feeding residents ______ Recreation/Leisure
______ Filing _____ Sign Language ______ Music
______ Telephone Etiquette _____ CPR/other first aid ______ Art
Other: __________________________________________________________________________________
Are there any days this summer that you know you will be absent? If so, please list:
_________________________________________________________________________________________
Please note that Volunteens are expected to complete at least five of the program’s eight weeks.
Preferred volunteer days (circle): Monday Tuesday Wednesday Thursday
Preferred service hours: From: ______________ To: _______________
(Hours are first shift only. No Volunteen may serve more than 8 hours per day. We suggest between 12 and 20
hours per week. First-year Volunteens will be limited to two days a week.)
T-shirt size (Adult) Small Medium Large XL XXL XXXL (Please circle one)
In the space below, explain what you hope to gain from your experience at JIRDC:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
For Returning Volunteens:
Where did you serve last year? ____________________________________________________
Would you like to serve in the same position/area again this year? ___Yes ___No
If no, please give another location or activity you would like to explore: ___________________________

Medical Information
On rare occasions, an emergency requiring hospitalization and/or surgery develops. As a general rule,
anesthesia may not be administered to or surgery performed upon a minor without written permission
by his/her parent or guardian. Therefore, in order to prevent a dangerous delay, if an emergency does occur
and we are unable to contact the parent or guardian, the parent or guardian is asked to sign the release form
below.
In the event of injury or illness to my child, ____________________________(child’s
name), born ___________________ (mm/dd/yyyy), I hereby authorize the staff of J. Iverson
Riddle Developmental Center to secure whatever treatment is deemed necessary and,
if recommended by an attending physician, the administration of an anesthetic or surgery.
Parent or guardian’s signature: ______________________________________ Date: _____________
Allergies: (food, medications, insect stings or bites, etc.)
_________________________________________________________________________________________
Medications Currently Taken: (name of medication, dose amounts, frequency, etc.)
_________________________________________________________________________________________
Medical Concerns or Conditions: (epilepsy, asthma, diabetes, previous injuries to bones/joints, etc.)
_________________________________________________________________________________________
Doctor
Name
Office Phone
Office Location
Insurance Information
Insurance Company Name Policy #
Address City State Zip
Phone Number
Date of last Tetanus vaccination: ____________________
All Volunteens are required to have been administered a TB test within the last year with negative TB results. If a
TB test has been administered within the last year, you may bring proof of the negative TB results from your physician.
If proof cannot be submitted, then a two-step TB test will be administered to all new Volunteens at the J.
Iverson Riddle Developmental Center Medical Services Department free of charge. If you are a returning Volunteen
then you will receive a one-step TB test. All Volunteens are encouraged to have up-to-date immunizations.
Though not required, they can provide extra protection. If you have any questions on which immunizations your
Volunteen should have, please call the Employee Health Nurse, Vickie Whitworth at 828-433-2708.
For our employee health records, please check the appropriate space
Immunizations: ____ YES, my child’s immunizations are up-to-date
____ NO, my child’s immunizations are not up-to-date

Please complete all sections of this application, and obtain all signatures in highlighted areas, including
the recommendation form. Incomplete applications will not be
considered received until all components of the application are in.
My signature below acknowledges that the information I have submitted is correct to the best of my ability. I
agree to follow all rules and regulations set down by J. Iverson Riddle Developmental Center and the Volunteen
Program.
Signature of Volunteen Applicant _____________________________________ Date _______________
Parent/Guardian Consent
(Please read and initial each section, then sign and date at the bottom of the page.)
• I have assisted my child with the application process and grant permission for participation in the
Volunteen Program at J. Iverson Riddle Developmental Center
___________________
Parent/Guardian Initials
• I give my child permission to travel in a North Carolina state government vehicle, with a supervisor from
J. Iverson Riddle Developmental Center, on field trips related to his/her area of service or activities of the
Volunteen Program
___________________
Parent/Guardian Initials
• I give my child permission to be in the J. Iverson Riddle Developmental Center swimming pool as part of
his/her assignment with a resident or as part of a Volunteen Program activity. I understand that my children
will be under the supervision of a certified lifeguard during attendance at the pool.
__________________
Parent/Guardian Initials
• I grant permission for my child to be photographed, videotaped, filmed or recorded as part of his/her activities
in the Volunteen Program. I understand this media information may be used in community education
programs and to promote the Volunteen Program at J. Iverson Riddle Developmental Center. I understand
that approval is voluntary and may be withdrawn at any time by the parent/guardian through written notification.
I also understand that withdrawal of permission does not mean the photographs, videotapes, films
or tapes previously recorded will be withdrawn from JIRDC.
__________________
Parent/Guardian Initial
• If proof of negative TB test results (completed within the past 12 months) is not presented, I give permission
for a TB test to be administered by J. Iverson Riddle Developmental Center.
__________________
Parent/Guardian Initials
By my signature I reaffirm all agreements initialed above.
Signature of Parent/Guardian _________________________________________________ Date _______________
Relationship ________________________

2012 Volunteen Recommendation
Prospective Volunteen Name: _______________________________________________________
Instructions to Volunteen: Please present this request for recommendation to a teacher, church leader, civic
leader, or other adult outside your immediate family. Do not return other portions of the application without
this recommendation.
Instructions to the Person Making Recommendation: Please describe your observation of the above-named
youth that has expressed an interest in being a Volunteen at J. Iverson Riddle Developmental Center during the
summer of 2012. Return your recommendation to the Volunteen to enclose in his/her application.
Please describe what you believe are the applicant's strengths:
(Socialization skills, leadership abilities, citizenship . . .)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please describe what you believe to be the area(s) in which the youth needs on-going development:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please give suggestions as to the type of training/seminars that you think would benefit this teen as he/
she continues to mature:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________
Signature Relationship Date