On-line Application Forms

Please fill out the application as completely as possible. Once you submit the application you will not be able to retrieve it or change it. You will receive a confirmation e-mail shortly.

Volunteer Application (Adult)

Montefiore - Nyack Hospital
Positions include: book cart, patient, family, or visitor escort, business offices, family waiting rooms, non-clinical departments, etc.

Personal Information
First Name
MI
Last Name
Gender
DOB
Volunteer type
Select: Adult Volunteer
Street Address
Apt #
City
State
Zip Code
Home Phone
Cell Phone
Work phone
E-mail Address
Are You Related To Anyone At Nyack Hospital?
If yes, Name & Dept.
Relationship

Skills/Hours Requirements
Skills
What are your volunteer interests at Nyack Hospital?

Education/Employment
Work Experience (general)
Have you ever been dismissed or forced to resign from any job held? If yes, please explain.
May we contact your present employer for reference (select Yes or No):
Are you seeking paid employment at this time?
Have you ever worked for Nyack Hospital before? If yes, please give locations and dates.
Do you have a Social Security Number? (Select Yes or No)
If You Are Still Employed Please Answer the Following
Employer
Dates Employed
Address
Duties
Please Select The Highest grade Completed
If You Attended College, Please Enter Info On Last College Attended (Name Of School, Major, Dates Attended, Graduation Date (If Any)

Emergency Contact Information
Emergency Contact Name
Address
Apt #
Zip Code
City
State
Work Phone
Home Phone
Cell Phone

Non-Family Reference
Name
Phone
Address
Apt #
City
State
Zip/postal
Organization
Years Known

Volunteer Work Preferences
Enter Day of Week and Times For Each Day Volunteering; Also Enter Patient or Non-Patient Preference

Please Read carefully and Sign.

  • I understand that information contained on my application will be verified by Nyack Hospital Volunteer Department.
  • I understandthat this is an application for and not a commitment or promise of volunteer opportunity.
  • I understand that all hospital volunteers must follow New York State regulations for initial immunization screening, attend the required hospital orientation, and annually update both.
  • I will consider as confidential all information which I gain, directly or indirectly, concerning a patient, physician, or any other person.

  • I understand that a background check and drug test will be required to complete my volunteer application process.

  • My signature attests to the fact that the information that I have provided on my application, given verbally or provided on any other materials, is true and complete to the best of my knowledge. I authorize verification of any and all information submitted on this application.
Signature of Applicant
Date
For Internal Use Only