Welcome to Rochester General Hospital Volunteer Services Department

Adult (Non-Student) Volunter Application

First name
Name prefix
Middle Initial
Family/last name
Gender
DOB
Application 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
Former Rochester Regional Employee?
If "Yes":
Approximately when did you leave Rochester Regional Health
If "yes," what is the first and last name of your last leader/boss?
Your Availability:
When are you free to volunteer? (Check all that apply.)
Weekdays
Weekends
Morning
Morning
Afternoon
Afternoon
Evening
Evening
How did you hear about the program
Why do you want to volunteer? What is your hope/goal?
Personal References:
Name:
Street
Phone:
E-mail:
1.)
City
State
Zip code
Name:
Street
Phone:
E-mail:
2.)
City
State
Zip Code
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
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