SUNRISE ON WHEELS VOLUNTEER
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- Camilla Boone
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1 SUNRISE ON WHEELS VOLUNTEER ü Be at least 18 years of age ü Agree to a criminal background check ü Be willing to receive an annual flu vaccination ü Agree to volunteer two to three times per month, for a minimum of 1 year ü Interview with a Sunrise on Wheels Coordinator and if required, with a Hospital Volunteer Coordinator ü Provide proof of an annual physical as per individual hospital s requirements ü Be willing to receive an annual tuberculosis (TB) screening ü Adhere to Sunrise on Wheels and hospital policies & procedures ü Provide proof of immunity to measles, mumps and rubella (MMR), chickenpox and tetanus, diphtheria and pertussis (Tdap.) ü Follow through with any additional training Sunrise on Wheels and the hospital volunteer department may require REQUIREMENTS 2018 SUNRISE ASSOCIATION
2 FOR OFFICE USE ONLY PLEASE DO NOT WRITE IN THIS AREA Date Received Initial Interview Hospital Connected with VO Cleared Start Date Term Date Date of Application: Personal Information Volunteer Application Name: _ Social Security Number: - - Date of Birth: Address City: State: Zip Code: Home Phone: Cell: address Occupation: Employer or School: Employer / School Address: City: State: Zip: Work Phone: Languages Spoken: Education: Training or Certifications pertinent to child care: Do you have any physical limitations? If so, specify: Have you ever been convicted of a felony or misdemeanor other than minor traffic offenses? If so, please explain. Emergency Contact Name: Relationship: City: State: Zip: Home Phone: Cell Phone: VOLUNTEERS MUST HAVE ALL REQUIRED VACCINES UP TO DATE. ANNUALLY, ALL VOLUNTEERS MUST GET THE FLU SHOT AND PPD TEST
3 Previous Hospital or Community Volunteer Experience (Use additional sheets if necessary) Where: When: Phone: Supervisor: Your Role: Where: When: Phone: Supervisor: Your Role: What type of child care experience, if any, do you have? (If babysitting/nanny, please indicate age of child and name of parent/contact info): Do you have any experience in working/volunteering with children with cancer/chronic illnesses/ special needs? Please describe: Why do you want to volunteer in a hospital environment? Please specify what personal skills/characteristics you will bring to Sunrise on Wheels to fulfill the special needs of the children: How did you hear about Sunrise on Wheels?
4 Which of the following hospitals are you interested in joining? (Please check all that apply.) The Children s Hospital at Montefiore: (Bronx) Mondays 10:00 AM 4:00 PM Thursdays 10:00 AM 4:00 PM (Various Sessions Available) Goryeb Children s Hospital (Morristown, NJ) Mondays 10:00 AM - 1:00 PM Cohen Children s Medical Center: (Queens) Tuesdays 9:30 AM - 12:00 PM Tuesdays 12:00 PM - 2:30 PM Tuesdays 2:00 PM - 4:00 PM Wednesdays 9:30 AM - 12:00 PM Wednesdays 12:00 PM - 2:30 PM Fridays 9:30 AM - 12:00 PM Mt. Sinai Medical Center: (Manhattan) Mondays 10:00 AM - 1:00 PM Tuesdays 10:00 AM - 1:00 PM Memorial Sloan Kettering Cancer Center: (Manhattan) Tuesdays 1:00 PM - 3:00 PM Tuesdays 3:00 PM - 5:00 PM Wednesdays 1:00 PM - 3:00 PM Wednesdays 3:00 PM - 5:00 PM Maria Fareri Children s Hospital: (Westchester) Thursdays 9:00 AM - 12:00 PM Tuesdays 11:00 AM-2:00 PM Fridays 12:00 PM - 2:30 PM NYU/Langone: (Manhattan) Mondays 10:00 AM - 2:00 PM New York Presbyterian/Columbia: (Manhattan) Tuesdays 10:30 AM - 1:30 PM Hackensack University Medical Center: (NJ) Wednesdays 10:00 AM - 1:00 PM Maimonides Medical Center: (Brooklyn) Wednesdays 10:00 AM - 2:00 PM
5 References Please list 2 personal references (other than relatives) that we may contact who have knowledge of your character, experience and ability. Also, include 2 current or past employer references. Personal References: Name: Relationship: Phone: Length of time known: Name: Relationship: Phone: Length of time known: Professional References: Name: Length of time known: Phone: Position: Name: Length of time known: Phone: Position: Applicant Signature: Date: Print Name:
6 AUTHORIZATION TO CHECK CRIMINAL RECORDS I,, hereby authorize the Sunrise Association and/or Sunrise on Wheels to obtain information pertaining to any charges I may have for federal and state criminal law violations. This information will include convictions committed upon minors and adults, and will be gathered from any law enforcement agency of this state or any other state or federal government to the full extent permitted by law. I understand that such access is for the purpose of considering my application as a volunteer and that I expressly DO NOT authorize the Association, its directors, officers, employees, or other volunteers to disseminate this information in any way to any other individual, group, agency, organization or corporation. Signed: Date: (Signature of Applicant) PLEASE RETURN APPLICATION TO: Cindy Harwin Coordinator, Sunrise on Wheels 15 Neil Court, Oceanside, NY Phone: fax: Cindy@SunriseLongIsland.org In New Jersey or Westchester, please contact: Lisa Lehrman Hospital Liaison and Senior Coordinator, Sunrise on Wheels Sunrise Day Camp - Pearl River c/o JCC of Mid-Westchester 999 Wilmot Road, Scarsdale, NY Phone: fax: Lisa@SunrisePearlRiver.org
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