Thank you for your interest in volunteering at MetroHealth.

Adult/College Application

* Application Entry Date

* First Name

* MI

* Last Name

What is your gender?

* Home Address

* City

* State

* Zip Code

U of R Student ID Number

If U of R student, please enter your CPU as your mailing address.

* Primary Phone Including Area Code (example: 5852752420)

* DOB (example:02/09/1969)

* E-mail

Previous volunteer experience

Work experience

Emergency Contact Information

Contact Name/Relationship

City

State

* Emergency Phone Including Area Code

Have you received the COVID vaccine?

Yes

No

Have you been convicted of or plead quilty to any offense?

If yes, explain all convictions.

Do you have any criminal charges pending at the current time?

If yes, explain:

Are you authorized to work in the US?

We have a variety of volunteer positions at off site locations (not at Strong Hospital) that require reliable transportation. Would you be interested in volunteering offsite?

Reference: Professional/Personal (please do not use relatives)

Name/Relationship

Phone Number

Commitment for Volunteers

The normal commitment is for one year or one semester, one shift (3-4 hrs.) per week. Is there any reason that you cannot honor this commitment?

Yes

No

If yes, why not?

Are you required to volunteer?

If yes, by whom and how many hours?

Interests

Tell us what type of volunteer work your are interested in.

Patient Contact

Other

Yes

No

Are you interested in volunteering wherever there is a need?

Or: Is there a specific Unit or Department that you would prefer, if available? (i.e. Gift Shop, Patient Discharge, etc.)

How did you hear about Friends of Strong?

Agreement and Signature

The University of Rochester values diversity and is committed to equal opportunity for persons regardless of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status protected by law. Further, the University complies with all applicable nondiscrimination laws in the administration of its policies, admission, employment, and access to and treatment in University programs and activities.

I hereby certify that the information herein is correct, and I understand that any misrepresentation, including omission of information when discovered, will result in termination. I am also aware that a criminal background check may be performed. I agree that Friends of Strong Memorial Hospital may contact my references. I understand that all volunteers must follow New York State regualtions for initial immunization screening and complete the required hospital orientation and update both annually. I understand that all information that I may gain, directly or indirectly, concerning a patient, physicaian, or any other person is to be kept confidential. Failure to do so may result in termination of my volunteer position. I understand, if any of the information on this application has been falsified, or if information has been omitted, the Friends of Strong reserve the right to rescind any offer made through their program. I understand that as a Friends of Strong Volunteer I am donating my time and efforts to UR Medicine and will not be paid for my services.

In typing my name below, I understand and accept the above statements.

* Signature/Date

For Office Use Only

Shift

Interviewer

EH Cleared

Not Placed

Tentative Start Date

Exit Date

Background Check

Completed Date

Time Sheet Mailed?

#1 Start Date:____________________Exit Date:____________________

Notes: