Which campus are you applying to:

Program Applying For

( 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

State

* Zip/postal

* Phone (Home)

Phone (Business)

Phone (Mobile)

* E-mail

Physical residence if different from mailing

Current residence

Current residence continued

City

State

Zip/postal

Profile Picture (please upload a passport format picture of yourself in a .jpg or .png format)

How did you hear about us?

Have you ever volunteered/worked with NYULH before?

Are you an NYU University Student?

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.

* Department Supervisor

* Department Supervisor email

Have you ever worked or volunteered at NYU

If yes, which location?

Dates of employment/volunterism?

Do you know anyone who currently works or volunteers at NYU?

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?

Are you between 16-18 years of age?

Gender identity

Highest Level of Education Completed

Type of applicant

Authorized to work or study in the US?

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?

Previous employer

Company or Organization Name:

Dates from:

Dates to:

Title

Tasks Performed

Name/Title of Supervisor

Telephone

May we contact your supervisor?

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

Other Languages Spoken

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

* 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

Population of interest?   Please note:  Opportunities to volunteer with children are very limited

Question #3- Are you required to volunteer?

Court mandate, school requirements, college course work, etc.

If yes, how many required hours

Any required tasks to complete?

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.

* I agree

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