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 email shortly.

Volunteer Application (VolunTEEN)

Montefiore - Nyack Hospital
Please note that Junior Summer VolunTEEN opportunities do not include shadowing, direct patient care, or internship-like experiences. Positions include: book cart, patient, family, or visitor escort, business offices, family waiting rooms, and non-clinical departments. Junior VolunTEENS are placed according to the immediate needs of the hospital.

Personal Information
First Name
MI
Last Name
Volunteer type
Select: VolunTeen Student
Gender
DOB
Will you be 14 years old by July 1st? (If yes check box)
Street Address
Apt #
City
State
Zip Code
Home Phone
Cell Phone
Work phone
E-mail Address
Current School/Institution
Grade Level
Expected Graduation Year
T-shirt Size Selection (Cost - $30)
Father's/ Mother's/ Guardian's Name
Phone Number

Skills/Hours Requirements
Please list any sports, clubs, extra-curricular activities, or other commitments you have.
Skills
Do you play an instrument and if so which?
Do you engage in arts and crafts? (check if yes)
Will you be taking a vacation this summer? If yes, for how long?
What are your career interests?
Please list any volunteer experience you may have.
Why do you want to volunteer?
If volunteering is a requirement please enter the number of hours required.
If possible please indicate the days and times that you are likely to be available.
Do you have any physical condition or medical problem which needs to be considered in selecting a volunteer assignment? If so, please explain.
How did you hear about the Summer VolunTEEN program?
Do you plan on working this summer? If yes, please check the box.

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

Medical Information
Physician Name
Wheelchair/requires handicap access (check if yes)
Medical alert (If any)

Parent and Student Consent for Program Participation
  • I understand my son/daughter is applying to be a Junior VolunTEEN at Nyack Hospital.
  • I give Nyack Hospital permission to administer (2) PPDs and if documentation of titers or immunization for all childhood diseases (mumps, varicella, rubella, rubeola) is not being provided, lab work and/or immunization is permitted. A parent or guardian must be present at this time.
  • I give consent for Nyack Hospital to evaluate on-the-job injuries.
  • I give consent to administer emergency medical treatment as necessary.
  • My son/daughter is at least 14 years of age and entering the ninth grade, but not older than 17 years of age.
  • Your son/daughter is responsible for calling and informing us of any schedule change.
  • My signature (electronic printed name) attests to the fact that the information that I have provided on my application is true to the best of my knowledge.
    I understand that my son/daughter is applying to be a Junior VolunTEEN at Nyack Hospital. If you agree check box.
    Student Signature
    Date
    Parent Signature
    Date
    Photo Release Authorization

    I hereby authorize and permit Nyack Hospital or it's authorized agent, without compensation therefore, permission to photograph, publish, reproduce, record and use, with or without my name or the name for whom I am the parent or guardian, photographs, motion pictures, video tapes or audio tapes of me or the person for whom I am parent or guardian.

    I have been informed of the purpose of the photography and/or filming. I have the right to cessation of recording or filming at any time.

    I have a right to rescind consent for such photography/ filming up until a reasonable time before recording or film is used. I have the right to view the photgraph or film before its publication or broadcast and have the right to withdraw consent at anytime.

    I release Nyack Hospital from any legal liability that may arise from the release of the information requests. I agree that all photographs, motion pictures, negatives, prints, transparencies, digital copies and tapes made of me or the person for whom I am parent or guardian by Nyack Hospital shall be the exclusive property of Nyack Hospital, which in its sole discretion may use the materials as it sees fit.

    Any limitations which I may want to place on the Hospital's use of these photographs/video images is noted below:

    Limitations
    Student Signature
    Date
    Parent Signature
    Date