Volunteer Application

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

Thank you for your interest in becoming a Phelps Hospital volunteer.  Once your application is received, we will contact you.  Meanwhile, please note:

  • Phelps Memorial Hospital is a tobacco-free environment.
  • Volunteering requires clearance by your physician. A PPD test to determine possible exposure to Tuberculosis, as well as minimum blood work, will be done at the Hospital’s expense.
  • Volunteers who will have direct patient contact will be required to have a background check.
  • 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, disability 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 *
Are you under 18 years of age?
* If yes you will need to provide working papers.
If under 18 years of age, please supply parent’s email.
Are you legally allowed to work in the U.S. for any employer?
 
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.
Work Status *  
Physical Limitations *
* 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.
Reason for Volunteering at Phelps *
Referred By Relationship
Have you ever been convicted of a crime? *  
  Please Explain:
Days Available
Time Preferred
Length of Volunteer Commitment *

Emergency Contact/Relationship

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

Physician Information

Name * Phone *
       
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Security Question * What number is in the blue box?