Visiting Nurse Service

 
 
Meals On Wheels Volunteer Application
  1. Your Information

  2. First Name (M.I.)*
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  3. Last Name*
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  4. Address*
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  5.  
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  6. City*
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  7. State*
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  8. ZIP*
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  9. Home Phone
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  10. Work Phone
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  11. OK to call work?


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  12. Cell Phone
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  13. Email Address
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  14. Date Of Birth
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  15. Gender


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  16. Ethnicty/race (optional) - information is for reporting purposes only





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  17. Employed By
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  18. Occupation
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  19. Retired from
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  20. Former Occupation
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  21. Educational Background
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  22. Previous volunteer experience
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  23. Leisure time activities and interests/special skills
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  24. Foreign Languages
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  25. Area of Interest


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  26. Day/Days Available (check all that apply)





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  27. How did you hear about VNS Volunteer Services?
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  28. Are there any reasons why you may have difficulty in performing any of the essential functions of the volunteer job for which you have applied?


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  29. If "Yes", please explain
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  30. Are you presently carrying at least the minimum legally required auto insurance coverage?


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  31.  
  1. Reference Information

    Please provide us with two references you have known at least one year (not relatives) who we may contact to comment on your ability to volunteer. Please include daytime phone numbers if possible.

    Person 1

  2. Name
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  3. Relationship
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  4. Phone Daytime
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  5. Phone Evening
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  6. Cell Phone
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  7. Address
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  8. Person 2

  9. Name
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  10. Relationship
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  11. Phone Daytime
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  12. Phone Evening
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  13. Cell Phone
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  14. Address
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  15.  
  1. Emergency Contact Information

  2. Name
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  3. Relationship
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  4. Home Phone #
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  5. Cell/Work Phone #
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  6. Photo Release

    I do consent to and authorize the use and reproductions by Meals On Wheels of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

  7. I Agree
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  8. STATEMENT OF CONFIDENTIALITY

    I do willingly promise to hold in confidence all matters that come to my attention in the line of duty at Visiting Nurse Service of Rochester and Monroe County, including material from and about clients/patients and matters regarding colleagues. I will respect the privacy of the people who I serve and confer appropriately with those designated as my supervisors and/or administrators. Further, I will use in a responsible manner information gained in the course of my service at Visiting Nurse Service.

    I also certify that the information submitted on this application is true and accurate and I authorize VNS to verify my references.

  9. I Agree*
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  10. Enter the letters or numbers you see on the right into the box below it
    Enter the letters or numbers you see on the right into the box below it
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  11.  

Visiting Nurse Service of Rochester and
Monroe County, Inc.
(585) 787-2233
(800) 724-5727

2180 Empire Boulevard • Webster, NY 14580

 

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HomeCare Elite
 
 
  1. VNSDear Patient:

    We like to recognize VNS staff who are living our I CARE values and are providing you extraordinary care and service. Please let us know if you see our employees acting with Integrity, Compassion, Accountability, Respect, Excellence.



  2. Employee Name*
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  3. Employee Title
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  4. Comments*
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  5. Your Name
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  6. Your Email
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  7. Your Phone Number
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  8. *These fields are required.


  9. I CARE ~ Integrity, Compassion, Accountability, Respect, Excellence