Northwell Health is an Equal Opportunity Employer and a Voluntary Not-For-Profit Health System

Each Hospital/Facility has their own minimum age requirements *

Do you currently have any friends or relatives employed, volunteering, or on the Board of Trustees at any Northwell Health location (formerly known as North Shore LIJ Health System)? Please input the facitlity, department, name and relationship of each. *

Are you currently on the federal government's exclusion list for any reason, including having defaulted on a Health Education Assistance Loan (HEAL)? *

Are you the subject of a pending action or proceeding involving fraud or abuse in Medicare, Medicaid or other healthcare program? *

Have you ever been sanctionned as a result of alleged Medicare or Medicaid fraud or abuse? *

Have you previously worked or volunteered at Northwell Health (formerly known as North Shore LIJ)? *

Work status *

Volunteer preference *

Please provide two (2) references who are not family members: *
















*Please be aware that certain Hospitals/Facitilies may not offer evening and/or weekend hours*

I understand that I will not be paid for my service as a volunteer. I understand that I must complete ??? hours of service before any information regarding service hours is released.

Do you already have a definite placement? *

NORTHWELL HEALTH VOLUNTEER APPLICATION SIGNATURE PAGE

Please read the following statement carefully, and then acknowledge that you have read and agreed to it by providing your signature and/or eSignature at the bottom of the page. Please note that an eSignature is the electronic equivalent of a handwritten signature.

It is Northwell Health’s policy to provide equal opportunity and treat all individuals equally regardless of their age, race, creed/religion, color, national origin, alienage or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, genetic information or genetic predisposition or carrier status, marital status, partnership status, victim of domestic violence, or other characteristics protected by applicable law.

Applicant's Certification

I certify that all matters contained in this application are true, authorize their investigation, and agree that any misleading or false statements would render this application void and would be sufficient cause for my immediate dismissal. I understand that my volunteer engagement with Northwell Health (“engagement”) is dependent on providing all necessary documentation as required for my position including, but not limited to, the following: verification of education, employment history, professional licenses and certifications, required regulatory checks (including without limitation a check under the Sex Offender Registration Act), satisfactory completion of a medical examination, receipt of satisfactory references and attendance at required orientations and trainings.

I understand that as a condition of my proposed engagement, I may be required to undergo and pass a screening for alcohol and/or drugs. Should the screening reveal the presence of an illegal drug, misuse or abuse of a controlled substance, or use of other substances which may impair my behavior and/or ability to function, I may not be allowed to volunteer with Northwell Health.

I understand and agree that Northwell Health may share Personal Information with other companies acting on the Northwell Health’s behalf to provide employment verification services, may include assessment test providers, if applicable.

Northwell Health may share my Personal Information in connection with the sale or transfer of part or all of the business or, as appropriate, in connection with any legal requirement such as a court order or regulatory obligation. Northwell Health may also share my Personal Information upon request from a law enforcement agency. Northwell Health will not share, trade, rent or sell my Personal Information to other third parties without my consent, unless such possible sharing, trading and selling was disclosed to me when the information was originally collected.

I understand that I have the right to request access to my Personal Information in order to correct, update, modify, or ask for the deletion and blocking of my data. I can do this by contacting Northwell Health through my respective volunteer coordinator. If I request the deletion of my data, I acknowledge that applicable legal obligations may require that Northwell Health maintain such data.

I agree, if accepted, to provide acceptable proof of my age and identity, and to abide by Northwell Health’s policies, procedures and rules.

I understand that my engagement with Northwell Health will be at-will, meaning that I or Northwell Health may terminate the relationship at any time, or for any reason, with or without cause or notice.

By my signature below, I certify under penalty of perjury that all my statements in this completed application are true and complete, that I have read, understood, and agree to this entire application, including the foregoing statement above, and that I was given as much time as I needed to read and complete this application. I understand that any falsification or omission shall be sufficient cause for termination of my volunteer engagement with Northwell Health (which I acknowledge is at-will). My typed name shall have the same force and effect as my written signature.

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