Welcome to Rochester General Hospital Volunteer Services Department

2020 Summer Student Volunteer Application

Name prefix
First name
Middle Initial
Family/last name
Gender
DOB
Application date
For current High School students ONLY:
High School
Other HS (not listed)
HS Anticipated Graduation Date
For College Students ONLY:
College
Other College (not listed)
College Graduation (Anticipated Date)
Home address
Street
Apt
City
State
Zip/postal
Home phone
Mobile
Work phone
E-mail
Emergency Contact
Contact name
Relationship
Home phone
Work phone
Employment and Educational History
2019 Summer Sessions
Session #1 (Monday, July 1 -- Friday, July 26, 2019
Preference #1
Preference #2
Times Available for Session #1
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (3pm/4pm - 7pm/8pm
Session #2 (Monday, July 29 -- Friday, August 23, 2019)
Preference #1
Preference #2
Times Available for Session #2
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (3pm/4pm- 7pm/8pm)
How did you hear about program
Reason for Volunteering:
Have you ever been known by any other name?
If yes, what name were you known by?
When were you known by that name?
Please read and sign:I understand that any falsification of information on this application may result in immediate termination of the application/on-boarding process or as a volunteer with the Rochester General Health System.I authorize the Volunteer Services Department to contact my references.I agree that my acceptance as a volunteer is contingent upon my passing a medical examination. Please state below any physical condition you have which should be considered when you are assigned a volunteer position in the hospital, or which we should know in case of emergency.I understand that a volunteer is expected to observe confidentiality with respect to all patient information at all times, and that failure to do so may result in my personal liability to the patient and/or the hospital.
I agree


For office use only:
Health Screening
Background Check
Orientation
Wheelchair Training
Canine Visitation