Dear Prospective Volunteer, Thank you for your interest in the

Prospective Volunteer Welcome Letter – Southside Hospital. Revised: 02/02/2015

Dear Prospective Volunteer, Thank you for your interest in the Volunteer Program at Northwell Health Southside Hospital. The Northwell Health vision is to be a national health care leader, committed to excellence, compassion and improving the health of the community. Volunteers play a significant role in achieving this vision and are an integral part in delivering the highest quality of health care possible. Enclosed, please find all materials needed to begin the application process to volunteer at Southside Hospital. It is important to complete all forms fully. Once completed, please return the forms to the Front Desk at the main entrance of the hospital. The Volunteer Services Department will contact you with further instructions after reviewing your application.

An interview will be required as well as a mandatory orientation session before beginning your service. These times will be scheduled accordingly after your application is completed and approved to begin service. Please note, all application materials will be held for three months. After this time, if the application is still incomplete, all documentation will be removed from our files.

We thank you again for your interest in volunteering at Southside Hospital. If you have

any questions and/or concerns, please feel free to contact our office. We look forward to reviewing your application.

Kind regards,

Department of Volunteer Services

Southside HospitalNorthwell Health301 East Main StreetBay Shore, NY 11706631.968.3423

Thomas Turner

Prospective Volunteer Welcome Letter – Southside Hospital. Revised: 02/02/2015

Dear Prospective Volunteer, Thank you for your interest in the Volunteer Program at Northwell Health Southside Hospital. The Northwell Health vision is to be a national health care leader, committed to excellence, compassion and improving the health of the community. Volunteers play a significant role in achieving this vision and are an integral part in delivering the highest quality of health care possible. Enclosed, please find all materials needed to begin the application process to volunteer at Southside Hospital. It is important to complete all forms fully. Once completed, please return the forms to the Front Desk at the main entrance of the hospital. The Volunteer Services Department will contact you with further instructions after reviewing your application.

An interview will be required as well as a mandatory orientation session before beginning your service. These times will be scheduled accordingly after your application is completed and approved to begin service. Please note, all application materials will be held for three months. After this time, if the application is still incomplete, all documentation will be removed from our files.

We thank you again for your interest in volunteering at Southside Hospital. If you have

any questions and/or concerns, please feel free to contact our office. We look forward to reviewing your application.

Kind regards,

Department of Volunteer Services

Southside HospitalNorthwell Health301 East Main StreetBay Shore, NY 11706631.968.3423

Thomas Turner

Application for Volunteer Service – Southside Hospital. Revised: 02/02/2015

Application for Volunteer Service Northwell Health is an Equal Opportunity Employer and a Voluntary Not-for-Profit Health System

Today’s Date: ______/______/______

Please print in ink ☐ I am 18 years of age or older ☐ I am between the ages of 15 and 17

Last Name: _______________________________ First Name: ______________________________ Mid. Int.: ______ ☐ Mr. ☐ Mrs. ☐ Ms. Date of birth: ______/______/______ Social Security #: ______-______-______ Contact Information: Home Address: ____________________________________________________________________________________ (Street) (City/Town) (State) (Zip) Home Phone: (______) _____________________________ Cell Phone: (______) ______________________________ E-Mail: ___________________________________________________________________________________________ Emergency Contact Information: Please provide two emergency contacts.

Name: Phone Number: Relationship: Foreign Language Spoken:

Employment Information: If you have any friends or relatives employed, volunteering, or on the Board of Trustees at the Northwell Health, please provide the below information.

Name: Facility: Department: Relationship:

Have you previously worked or volunteered for the Northwell Health? If yes, please specify. ☐ Yes ☐ No __________________________________________________________________________________________________ (Facility) (Department) (Date(s)) I am currently: ☐ Employed ☐ Student ☐ Retired ☐ Unemployed ☐ Other __________________ Employer (if applicable): ____________________________________________________________________________ (Name) (City/Town) Education: ☐ High School ☐ College ☐ Graduate School Highest Degree: __________________________________ School presently attending: __________________________________________________________________________

For Office Use Only

Date Application Received: ________

Date Application Reviewed: ________

Application for Volunteer Service – Southside Hospital. Revised: 02/02/2015

Volunteer Information: How did you hear about the Northwell Health Volunteer Program at Southside Hospital? __________________________________________________________________________________________________ Why are you interested in volunteering at Southside Hospital? __________________________________________________________________________________________________ __________________________________________________________________________________________________ I prefer: ☐ Patient Contact ☐ Non-Patient Contact ☐ Clerical ☐ Where Needed I am interested in the following area(s). Please list all areas of interest. __________________________________________________________________________________________________ __________________________________________________________________________________________________ I am available to begin volunteering on: ______/______/______. Please provide your availability below. A marked box represents availability for volunteering.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday A.M. A.M. A.M. A.M. A.M. A.M. A.M. P.M. P.M. P.M. P.M. P.M. P.M. P.M. Eves Eves Eves Eves Eves Eves Eves Please note the hours are as follows: (A.M. – 8:00a.m.-Noon) (P.M. – Noon-4:00p.m.) (Eves – 4:00p.m.-8:00p.m.) Do you have definite placement? If yes, please specify. ☐ Yes ☐ No __________________________________________________________________________________________________ (Name of Supervisor) (Department) (Phone Number) Have you ever been convicted of or pleaded guilty to a crime (a misdemeanor and/or felony)? ☐ Yes ☐ No If yes, please explain below. __________________________________________________________________________________________________ __________________________________________________________________________________________________ I agree that the statements made in this volunteer application are true and correct, and have been given voluntarily. I understand that this information maybe disclosed to any party with legal and proper interest, and I release Northwell Health from any liability whatsoever for any such disclosure. I agree to abide by, accept, and perform my volunteer service within the traditions, standards and core values of the Northwell Health, and to hold as confidential any and all information I learn in conjunction with my volunteer service. I understand that I will not be paid for my service as a volunteer. I understand that I must complete 150 hours of service before any information regarding service hours is released. I must attend an orientation and training and submit a medical clearance. I will be required to submit an annual Health Assessment and have an annual PPD or screening test for Tuberculosis. I will be required to give permission for a criminal background check, social security number check, and a NYS Nurse Aide screening (if applicable). Applicant’s Signature: _______________________________________________________ Date: ______/______/____

4347 v.1

Notice Regarding Background Investigation / Authorization for Release of Information

As a condition to my employment, I understand Northwell Health may obtain information about me from a consumer

reporting agency for employment purposes. Thus I authorize Northwell Health and/or their agents to conduct a background check and to obtain consumer reports/investigative consumer reports that may include but may not be limited to:

• Criminal checks • National Sex Offender Search • Social Security Number Verification • NYSDOH • OIG / GSA • Education Verification • Employment Verification (including wage inquiry)

• Professional/Personal Reference Verification

• Professional License Verification • Motor Vehicle/Driving History Records • Pre-Employment Credit Report (finance

positions only)

Investigative consumer reports may include information about your character, general reputation, personal characteristics, etc. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

I acknowledge receipt of this NOTICE REGARDING BACKGROUND INVESTIGATION, NY Article 23 and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (if applicable) and certify that I have read and understand these documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Corporate Screening Services, Inc., another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original. In addition, as a condition of employment in Home Care Services (e.g., Home Health Aides, Personal Care Aides, etc.), I authorize Northwell Health and/or their agents to provide certain of my personal information and any required updates thereto to the New York State Department of Health Home Care Registry as required and limited by New York Public Health Law § 3613.

APPLICANT’S INFORMATION (please print) Name: Address: City: State: Zip: Social Security Number: Applicant’s Signature: Date Signed:

Human Resources: Address: Phone: Date of Birth:

(To be completed by HR only if an offer has been extended)

Note: If 1

8 Y

ears of age or older, p

lease comp

lete this au

thorization

form.

Volunteer Assignment Descriptions – Southside Hospital. Revised: 02/02/2015

Volunteer Programs Southside Hospital

Bell Hops Add a compassionate and personal dimension in the delivery of care to patients and their

families and assist staff in the delivery of care, as needed.

ED Ambassador Program Round on patient units and Emergency Department to help address non-clinical needs

(i.e. pillows, blankets, refresh ice water, answer call bells/lights, etc.).

Greeter Greet patients providing them with directions Provide assistance to patients and families, ensuring their arrival at their desired

destinations.

Information Desk Welcome patients and visitors to the hospital in a professional manner. Answer patient and visitor inquiries. Answer phones and contact clinical departments, as needed.

Gift Shop Provide a customer-focused environment for our patients and families. Assist in the sale and stocking of merchandise.

Friendly Visitor Visit with patients and create conversation during their stay.

Mealtime Feeders Assist patients during meals that are in need of help.

Clerical Assignments Filling, copying, collating, answering of phones, data entry, and running of errands

Requirements: Minimum, 150 hours of service per year Minimum, 4 hours of service per week

*Please note: All volunteers will be given job-specific training before beginning their service.

Department of Volunteer Services (631) 968-3423