February 4, 2012 8:16pm

Volunteer Application Form

Phelps Memorial Hospital Center
701 North Broadway, Sleepy Hollow, NY 10591

Please Note: No question on this application is asked for the purpose of limiting or excluding any applicant’s consideration for volunteer placement based on race, color, religion, age, sex, marital status, sexual orientation or national origin. Confidentiality will be maintained.

* Denotes required field.

Your Information

First Name * Last Name *
Class *
     
     
Home Phone * Work Phone
Cell Phone Email *
Address Line 1 * Address Line 2
City * State *
Zip Code * Sex *
Birth Month * Birth Day *
   
Education Level *    
Occupation *
* Please enter ‘none’ above
if this field is not applicable
to you.		 Employer *
* Please enter ‘none’ above
if this field is not applicable
to you.
   
Special Skills / Training *
* Please enter ‘none’ above if this field is not applicable to you.
Volunteer / Community Experience *
* Please enter ‘none’ above if this field is not applicable to you.
Referred By    
Have you ever been convicted of a crime? *  
  Please Explain:
Days Available
Time Preferred
       

Emergency Contact/Relationship

Name * Relationship *
Home Phone * Work Phone *
Cell Phone *    

Physician Information

Name * Phone *
       
Medications
Physical Limitations, if any *
Do not fill out this field, it is here to prevent spam.

<< Return to Previous Page