NYU Langone Health Volunteer Application Form

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OK New User Details User ID User ID (verify) Password Password (verify) Which campus are you applying to: NYU Langone Hospital - Brooklyn NYU Langone Hospital - Long Island NYU Langone Hospital - Long Island Mentorship Program NYU Langone Medical Center NYU Langone Orthopedic Hospital Program Applying For College Community Teen ( Please note: NYU Langone Medical Center includes Tisch, Kimmel, and Hassenfeld Children's Hospital as well as the Perlmutter Cancer Centers and other ambulatory sites. NYU Langone Hospital- Brooklyn includes NYU Langone Hospital- Brooklyn and the Family Centers at NYU Langone) Please complete all information in this section. Items highlighted are required. * First name Middle name * Last name Maiden name Nickname * Current mailing address Mailing address continued * City StateAB AK AL AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT * Zip/postal * Phone (Home) Phone (Business) Phone (Mobile) * E-mail Physical residence if different from mailing Current residence Current residence continued City State AB AK AL AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT Zip/postal Uploading... Profile Picture (please upload a passport format picture of yourself in a .jpg or .png format) remove How did you hear about us? n/a Doctor/Nurse Employee Friend Internet NYU Service Fair Other School Self/Walk-In TV/Radio/Newspaper Volunteer Have you ever volunteered/worked with NYULH before? Yes No Are you an NYU University Student? Yes No Are you a direct placement? Direct placements are volunteers that are coming in as a staff referral or through a third party organization and have already interviwed with a staff member. Yes No * Department Supervisor * Department Supervisor email Have you ever worked or volunteered at NYU Yes No If yes, which location? Dates of employment/volunterism? Do you know anyone who currently works or volunteers at NYU? Yes No If yes, please complete the information below: Name Title Department Availability Please enter duration of times for the days which you are available, for the days you are not available enter N/A. * Sunday * Monday * Tuesday * Wednesday * Thursday * Friday * Saturday Demographics This information is used only to help us get a better idea of the demographics of our volunteers. Items highlighted are required. (copy) Are you 18 years of age and older? Yes No Are you between 16-18 years of age? Yes No Gender identity Female Gender Non-Binary Gender Queer Male Other Transgender Female Transgender Male Highest Level of Education Completed High School or GED Trade Certification Associates Degree Bachelor's Degree Master's Degree M.D. PhD High School GED Doctoral Degree Military Vocational/Trade School Some College Other Type of applicant Summer Year-round Fall Authorized to work or study in the US? Yes No Employment or Volunteer Experience

Most recent employer

Company or Organization Name: Dates from: Dates to: Title Tasks Performed Name/Title of Supervisor Telephone May we contact your supervisor? Yes No

Previous employer

Company or Organization Name: Dates from: Dates to: Title Tasks Performed Name/Title of Supervisor Telephone May we contact your supervisor? Yes No Educational Information

High School (if a current student)

* School Name (if not applicable, please type in N/A): School Address Highest Attended

College/University 1

College/University (if applicable) School Name School Address Major Highest Grade Graduation Date/Anticipated Graduation Date Degree Completed

College/University 2

College/University (if applicable) School Name Major Highest Grade Graduation Date/Anticipated Graduation Date Degree Completed Emergency Contact Please provide your emergency contact information * Contact name Work Phone * Cell Phone * Email Address * Relationship Skills and Interests Please complete the following information to help us learn more about you. Skills/Interests Computer Skills --MS Access --MS Excel --MS InfoPath --MS Outlook --MS Power Point --MS Publisher --MS Word --Typing --WINDOWS Skills/Interests --Arts and Crafts --Drawing --Exercising --Horticulture --Magic --Painting --Photography --Sewing --Singing/ Musician --Writing --Yoga Knitting/ Crocheting Other Languages Spoken Afrikaans Akan Aklanon Albanian Aleut Algerian Amharic Anishinaabemowin Arabic Aramaic Arawakan Armenian ASL Avestan Ayapathu Aymara Azeri Bamwe Bantu Basa Basque Belarusan Bemba Bengali Berber Bicol Bisaya Bobangi Bosnian Brahui Breton Bukusu Bulgarian Burmese Butuanon Byelorussian Cambodian Cantonese Catalan Cayuga Cebuano Ch'ol Chaldean Chamorro Chechen Chewa Chinese Chinook Chorti Coptic Cree Creole Croatian Czech Danish Dari Demonh'ka Dinka Dothraki Dutch Ebu Eggon Egyptian Emakua English Eskimo Estonian Etruscan Fang Faroese Farsi Filipino Finnish Flemish Frankish French Fujanese Fuzhounese Gaelic Gaelic (Irish) Gaelic (Scottish) Gaelic (Welsh) Galician Gamilaraay Ganda Gaulish Gbari Georgian German Gevove Gilbertese Gothic Greek Guarani Gujarati Guyanese Creole patois Haida Haitian Creole Hakka Halaka Hausa Hawaiian Hebrew Hiligaynon Hindi Hmong Hokkien Hungarian Icelandic Igbo Ilocano Ilonggo Indonesian Ingush Inuit Inupiat Italian Japanese Jita Kachi Kakwa Kalanga Kannada Kapampangan Kapampangan Karelian Kashmiri Katcha Kazakh Kerewe Khmer Khowar Kiga Klallam Klingon Kongo Konkani Korean Koyo Kurdish Lakhota Laotian Latin Latvian Lebanese Lingala Lithuanian Lozi Luganda Luwian Lycian Lydian Mabwe Macedonian Malay Malayalam Maliseet Maltese Mandarin Mandinka Manx Maori Mapudungun Marathi Masaba Mawu Mayan Mayangna Miami Minbari Miskitu Mixtec Mohawk Mongolian Mpongwe Nahuatl Nande Nauruan Navajo Ndebele Nepali Nkwen Norwegian Nyamwezi Occitan Ojibwe Olkola Olutec Onondaga Oriya Oromo Oykangand Pahlavi Pakahn Pali Papiamento Pashto Pende Persian Phoenician Phrygian Pidgin Piraha Polish Popoluca Portuguese Potawatomi Prussian Punjabi Quechua Rasta Rejang Romanian Romany Rotuman Russian Saanich Samoan Sanskrit Seneca Serbian Seri Shanghainese Shi Shona Sicilian Signing Exact English Sindhi Sinhala Slovak Slovene Sogdian Somali Sorbian Spanish Sranan Sudovian Sumerian Swabian Swahili Swedish Tagalog Taishanese Taiwanese Tajik Tamazight Tamil Tarahumara Tarok Tatar Telugu Teochew Thai Thracian Tibetan Tigrinya Tlingit Tocharian Tongan Treu Chau Turkish Turkmen Twi Ukrainian Ulwa Umbrian Urdu Uyghur Uzbek Venda Veps Vietnamese Visayan Votic Warlpiri Welsh Wolof Xhosa Yaka Yao Yemba Yiddish Yoruba Yupik Zoque Zulu Professional Reference Please provide a professional reference. This reference cannot be a relative, friend, or partner.

PLEASE NOTE: A VOLUNTEER CHARACTER REFERENCE FORM WILL BE SENT TO CONTACT PROVIDED

(copy) * Name Title * Phone Phone 2 * E-mail Relationship Employer Pastor/religious leader Law enforcement Teacher Professional Other * Question #1 - Goals for Volunteering Why would you like to volunteer at NYU Langone Health? What do you hope to gain from the experience?

Question #2- What are your area(s) of preference?

Role Preference- Check all that apply Child Life (Medical Center and Long Island only) Emergency Department (All campuses) Guest Services (Medical Center only) Immediate Care Inpatient (Medical Center and Long Island only) Outpatient (Medical Center and Brooklyn only) Population of interest?   Please note:  Opportunities to volunteer with children are very limited Children Teens Adults Seniors No Preference

Question #3- Are you required to volunteer?

Court mandate, school requirements, college course work, etc. Yes No If yes, how many required hours Any required tasks to complete? Yes No If yes, then please explain Agreement I understand and agree that submitting this application form does not automatically register me as a volunteer at NYU Langone Health. I am aware there are certain qualifications I must meet including orientation, medical clearance, background check (depending on volunteer job assignment), and a 9 month commitment (9 month commitment does not apply to summer only applicants). By submitting this form, I attest that the information I have provided on the form is true, accurate, and NOT provided by a third party.