Volunteer Application | Visiting Nurse Service – Rochester, NY – Home Health Services, Hospice, Home-delivered Meals

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Volunteer Application

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Meals on Wheels Volunteer Application

Fill out the following information before submitting your volunteer application.

Required *

First Name (M.I.)

Last Name

Address

City / Town

Zip

Home Phone

Work Phone

OK to call work? Yes No

Cell # (optional)

E-mail (optional)

Birth Date (year optional):

Gender Male Female

Employed By

Occupation

Retired from

Former Occupation

Educational Background:

Previous volunteer experience:

Leisure time activities and interests/special skills

Foreign Languages:

Area of Interest

How did you hear about VNS Volunteer Services?

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? Yes No

If "Yes", please explain:

Driver's License #:

Make of Vehicle

License Plate:

Have you been convicted of any moving violations within the last 12 months? Yes No

Are you presently carrying at least the minimum legally required auto insurance coverage? Yes No

Have you ever been convicted of a felony? Yes No

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.

Name

Relationship

Phone Daytime

Phone Evening

Address

Name

Relationship

Phone Daytime

Phone Evening

Address

EMERGENCY CONTACT

In case of emergency, please contact:

Name

Relationship

Home Phone #

Work Phone #

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.

I agree *

Visiting Nurse Service of Rochester and
Monroe County, Inc.
585.787.2233

2180 Empire Boulevard • Webster, NY 14580