Records Release And Counselor Request Form printable pdf download

VolunTeen School Records Release

and Counselor Request Form

Kennestone Hospital

Please print.

I give permission for release of any information or records requested.

Student’s Name: _____________________________________________________________________________

Name of School: _____________________________________________________________________________

Name of Counselor: __________________________________________________________________________

Email Address of Counselor: _______________________________fax #_________________________________

Signature of Student: _________________________________________________________________________

Signature of Parent / Guardian: _________________________________________________________________

STUDENT – DO NOT WRITE BELOW THIS LINE AND RETURN WITH APPLICATION

Guidance Counselor – please print. The student listed above has applied for the WellStar Kennestone Hospital

Summer VolunTEEN program. Please complete the below information and return this form as soon as possible,

as your recommendation is a requirement to determine the students eligibility for our program.

No

1. Student’s GPA: _____________

2. Is the applicant responsible?Yes

Comments: _________________________________________________________________________________

3. To your knowledge, does the applicant have any physical or emotional concerns that would affect their ability

Yes

No

to work with patients?

If yes, please explain.

___________________________________________________________________________________________

4. Did the student have consistent attendance during the school year with limited tardiness?Yes No

Comments: _________________________________________________________________________________

5. Does the student have any major discipline or honor violations? Yes

No

______________

6. Any additional comments: ___________________________________________________

____________________________________________________________________________________

Counselor’s Signature___________________________________________________________________________________

Date

Please fax completed form back to WellStar Kennestone Hospital at 770-793-7128

Department of Volunteer Services

677 Church Street * Marietta, GA 30060

770-793-7128

770-793-7120 (phone) * (fax)

Records Release And Counselor Request Form