Volunteer Test page Home » Volunteer Test page I am applying to be a(n)...(Required) Adult Volunteer College Volunteer Junior Volunteer Date(Required) MM slash DD slash YYYY Name(Required) First Last DOB(Required) MM slash DD slash YYYY Email Address(Required)Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Phone(Required)T-shirt Size(Required)Are you a year round resident?(Required) Yes No If not, what months are you available?(From _________ To _________)Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact/Relationship(Required)Emergency Contact's Phone(Required)Currently you are employed?full timepart timeunemployedretiredWhy do you want to volunteer at Crouse Hospital?Employment/Volunteer History: Starting with your most recent position, list all positions and activities including self-employment, volunteer work and all significant experience. Add RemovePlease list Employer name & address, job title, dates, job duties and reason for leaving. The typical Crouse volunteer works one 4-hour shift per week. We ask that you are able to give us a commitment of 40 hours over a four month period. Are you willing to make such a commitment? Yes No Areas of service in which you might be interested in volunteering: Emergency Dept Clinical Areas Surgery Centers Nutrition Information Desk Transport Spiritual Care Clerical Office Select AllDo you wish to have patient contact? Yes No Are you interested in clerical assignments? Yes No Can you be available for extra training assignments? Yes No Volunteer AvailabilityPlease select all that apply: I am available for an 8 a.m. - noon shift on the following days Sunday Monday Tuesday Wednesday Thursday Friday Saturday Select AllPlease select all that apply: I am available for a noon - 4 p.m. shift on the following days Sunday Monday Tuesday Wednesday Thursday Friday Saturday Select AllPlease select all that apply: I am available for a 4 - 8 p.m. shift on the following days Sunday Monday Tuesday Wednesday Thursday Friday Saturday Select AllHave you ever been convicted of any felony (which does not include minor traffic offenses, etc.)? Include a plea of guilty or no contest. NOTE: Conviction for a felony is not necessarily grounds for disqualification. Yes No If yes, please explain.References: Please list complete information below: name, address, relationship and email addresses for two references (not relatives). Email is the preferable way to contact for immediate action. Reference 1(Required) First Last Relationship(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Reference 2(Required) First Last Relationship(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) College Applicants OnlyAre you currently a college student? If so, what year?(Required)Year 1Year 2Year 3Year 4Graduate StudentNo, I'm not a college studentCurrent Address (for students)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyName of College or University(Required)Major/MinorDo you have any school/work related hours of service?YesNoIf yes, how many?Junior Volunteers OnlyHealth Career Exploration Program Member(Required) Yes No Present School(Required)Grade(Required)Parent/Guardian Contact InformationThis information MUST be fully completed by a parent or guardian. Please provide those numbers at which we could contact you in case of emergency.Parent/Guardian Full Name (First & Last)(Required)Relationship(Required)Emergency Contact's Phone(Required)Educational InformationWhat's your favorite subject?What extracurricular activities do you participate in?What honors have you received?Parent/Guardian ConsentI am aware of, encourage, and support my son’s/daughter’s decision to volunteer in the Crouse Health Junior Volunteer Program. I understand that a decision to volunteer in this program requires a commitment of a minimum of 4 hours per shift and support the hospital and my child in his/her effort to honor the commitment. If a letter of recommendation or completion is requested you must completed 40 hours of service prior to receipt. I also understand that all volunteers at the hospital must meet health office requirements which include submission of copies of proof of medical examination within one year of the application and a record of inoculations. In addition, all volunteers are required to undergo a tuberculosis skin test administered by our health office. Your signature indicates that we have your permission to complete the above requirements.Parent/Guardian Name First Last Date MM slash DD slash YYYY
