PT OT Volunteer Application Final

8/12/2019 PT OT Volunteer Application Final

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Physical Therapy Department

Occupational Therapy DepartmentVOLUNTEER APPLICATION

Date: 2/15/2014

Last Name: __ Hall ___________________ First Name____ Ashley ____________________

Date of Birth: ____ 12/03/1992 __ Age: 21 _ Gender: M F

Street 1:________ 1113 east 58 th st ____________________________________________________________

Street 2: ____________________________________________________________________

City: ______ Brooklyn ________________________________ State: _ NY _____ Zip: _ 11234

Home Phone: ______________________ Work Phone: ______________________

Cell Phone: __ 347-701-7152 _____________________

Email: [email protected]_

Please check off all that apply:

Employed (Full or part time) Self-employed/freelance Unemployed Retired

Under 16 years of age Student (Full or part time ) 16 or 17 years of age

Are you authorized to work or study legally in the United States? Yes No

Highest Level of Education Completed:

Associates Degree Bachelors Degree Doctoral Degree GED High SchoolMasters Degree Military Some College Vocational/Trade School Other*

* If other, please specify : _________________________________________________________

Summer Only Applicant: Yes No

Current School: _ Cuny- Hunter College

Expected degree:_ Bachelor of Arts ________________ Expected Graduation date:_ June 2016

Employer: _____________________________________________________________________

Employer Address: ________________________________________________________________________

______________________________________________________________________________
mailto:[email protected]_mailto:[email protected]_mailto:[email protected]_mailto:[email protected]_


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Availability

Can you make a 120hour commitment to volunteer at NYU Langone Medical Center at the same day andtime every week?

Yes, I can make a weekly commitment for : No , I cannot make a weekly commitment for 6 or 12months but

6 Months 12 months I can commit to: ________ months.

Please circle the days and write in the times for each day you are available to volunteer, the same day &time, each week.

Example : Wednesday Thursday Friday Saturday Sunday

10 am 2 pm 6 10 pm ____ 8 am 10 pm ________

Days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Hours: ______ __ 10am-3pm _ _ 10am-3pm __________ ________ ________ _______

Language(s) spoken and/or written other than English _______________________________________________________________________________

Emergency contact information:

Name: ____ Vashti Hall

Relationship ____ Mother _________________________________________________________________

Home Phone: ______________________ Work Phone: ______________________

Cell Phone: ___ (917)_742-1134 ___________________

Email: _______________________________________________________________________


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Reference

Please provide a reference letter from the contact person below (CANNOT BE A RELATIVE)

Name: __ Deborah Parker ____________

Address: ______________________________________________________________________

______________________________________________________________________________

Relationship __ She is the director of the Womens resource center at the Borough of ManhattanCommunity College. ________

Home Phone: ______________________ Work Phone: __ (212) 220-8165 ___

Cell Phone: _______________________

Email: [email protected] _____

Volunteer Experience

Please list your most recent volunteer experience:

Name of organization ____Coney Island Hospital _________

Volunteer Dates: From _ February 2009 to November 2009 __________

Name of supervisor and phone # _ Misty Teitel (Director) 718-616-3161 ___

Please describe volunteer duties: _Deliver specimens to the appropriate lab, assist the Nurse as needed,

greet visitors/ direct visitors, manage front desk, stock medical supplies.

Have you ever volunteered at NYU Langone Medical Center before? No Yes

If Yes, when? ____________________________________________________________________


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Questions:PLEASE NOTE: YOUR APPLICATION WILL NOT BE CONSIDERED UNLESS ALLQUESTIONS ARE COMPLETED.

Why would you like to volunteer at NYU Langone Medical Centers Physical Therapy /OccupationalTherapy Department?What do you hope to gain from this experience?

I believe that the NYU Langone Medical Centers PT/OT department will provide me with the bestexperience and knowledge about the field. I hope to gain a better firsthand understanding of physical andoccupational therapy and stronger interest in the field, I also hope to learn ways to take the career ofPhysical therapy/Occupational therapy further.

List and explain any additional volunteer experience you have had in a hospital, medical center ordoctors off ice related to Physical Therapy/Occupational Therapy

_I have volunteered at Coney Island Hospital but the position was not related to Physical

Therapy/Occupational Therapy. _

Have you ever been convicted of a crime? If so, please specify nature, date of conviction and penalty. __ No. ______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Are you required to volunteer? (i.e. court mandate, school requirements, college coursework, etc.) Pleasedocument specific information for this requirement.

___I am interested in going into the field of either Occupational Therapy or Physical Therapy. Some of

the programs require that I have Volunteer experience in the field before I can apply to either program. I

am also not sure if I would like to pursue a career in Occupational therapy or Physical Therapy. So this

would be a great decision making experience.____________________________

Certification of Application

I understand and agree that submitting this application form does not automatically register me as avolunteer at NYU Langone Medical Center. I am aware there are certain qualifications I must meet

including orientation, medical clearance, background check and a 120 hour commitment. By submittingthis form, I attest that the information I have provided on the form is true, accurate and NOT provided bya third party.

Name Ashley Hall Date 2/15/2014 ___________

Documents

PT OT Volunteer Application Final