Unity Volunteer Application

Notifications to Myrna I. Rivera myrna.i.rivera@rochesterregional.org https://www.rochesterregional.org/volunteer/volunteer-at-unity-hospital/volunteer-application/https://auth.rochesterregional.org/join-our-team/volunteer-at-unity-hospital/volunteer-application

Become a Unity Hospital volunteer today and join a very special team. Fill out the form below and click "Submit" to have a representative contact you with additional information about the wonderful volunteer opportunities that are waiting for you at Unity. Or, call us at 585.723.7101.

Which location would you like to volunteer at?*

Unity HospitalSt. Mary's CampusEdna Tina Wilson Living CenterNo preference

Name*

First NameLast Name

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Date of Birth*

Date

High School:

College

Other education:

certifications, training, etc

Upload Resume:

Experience:

Why do you want to volunteer?

Have you ever worked for a Rochester Regional Health affiliate(s) in the past?*

YesNo

If yes, name of RRH affiliate(s):

How did you hear about our volunteer program?

Family, Friend, Unity Employee, Brochure, Website, ...

How many hours a week are you available to volunteer?

Preferred days / times you'd like to volunteer?

PLEASE DO NOT USE RELATIVES.Please list the names, addresses, and telephone numbers of at least two (2) people who can vouch for your reputation, character, and work record, and who have known you for at least one year. One of these should be a work reference (if applicable).BY SUPPLYING THE INFORMATION BELOW, YOU ARE AUTHORIZING UNITY HEALTH TO PERFORM REFERENCE CHECKS.

Reference #1 (non-relative) - Name*

First NameLast Name

Reference #1 - Phone Number*

Reference #1 - Email

example@example.com

Reference #1 - Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference #1 - Relationship to you?*

Reference #1 of 2

Reference #2 (non-relative) - Name*

First NameLast Name

Reference #2 - Phone Number*

Reference #2 - Email

example@example.com

Reference #2 - Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference #2 - Relationship to you?*

Reference #2 of 2

Emergency Contact - Name*

First NameLast Name

Emergency Contact - Phone Number*

Emergency Contact - Relationship to you*

Emergency Contact

APPLICANT'S STATEMENT: 1. I understand the acceptance to volunteer will be on a 3 month introductory basis.2. If accepted for a volunteer assignment with Rochester Regional Health, I agree to abide by Unity’s rules and regulations.3. The information contained in this application is complete and true to the best of my knowledge.4. Any misrepresentation or omission of facts will be cause for immediate dismissal.5. I authorize Rochester Regional Health to contact any references for full information.6. I agree to have a health assessment at Rochester Regional's Employee Health office if I am offered a volunteer assignment, and ANNUALLY THEREAFTER.7. I understand that my volunteer assignment is entered into voluntarily and that I am free to resign at anytime, and that Rochester Regional Health may terminate the volunteer relationship at any time whenever it is in the best interest of Rochester Regional to do so.8. I understand that as a volunteer, I will be expected to observe confidentiality with respect to all information I may possess regarding my interactions with Rochester Regional Health, its clients, patients, residents, and staff, and any knowledge of the contents of confidential records. Failure to adhere to this agreement is grounds for immediate dismissal. I also agree to maintain confidentiality after I leave Rochester Regional Health for whatever reason.9. I hereby authorize Rochester Regional Health to obtain personal reference, criminal record and CNA registry checks.10. By submitting this form, I hereby certify that all of the information submitted is true, accurate and complete.

Rochester Regional Health is an Equal Opportunity Organization and complies fully with Federal and New York State laws prohibiting discrimination because of sex, age, color, creed, marital status, nationality or origin, ancestry, availability for military service, disability, or any other characteristic protected by federal, state, or local law.

Unity Volunteer Application

Education

Work Experience

References