Nuvance/Northern Dutchess Hospital Volunteer Application – Bard College Health Professions Advising Forms

Adult Volunteer Application

Thank you for your interest in becoming a Northern Dutchess Hospital (NDH) Volunteer. Supporting others will lead to many rewarding experiences. Volunteering is a great way to meet new people, learn or expand skills, share your strengths and knowledge, and contribute to our healthcare community. Volunteers are much appreciated, both by patients and staff.

I look forward to meeting with you and discussing volunteer possibilities.

James (Jay) Glynn, Volunteer Services Coordinator, Northern Dutchess Hospital / Nuvance Health

[email protected]/(845) 871-3470

Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone(Required)

Email(Required)

What pronouns do you use?

Additional Language(s) Spoken

Add rows as needed

Prior Volunteer and/or Employment Experiences

Volunteer or Job Title

Location

Dates of Service

Summarize Duties

Add rows as needed

Volunteer Interests:(Required)

Please check all that may apply

Neugarten Birth Center

Med Surg, Rehab.

Ambulatory Surgery Unit

Patient and Visitor Guest Services

Art Therapy/Activities

Music Therapy/Performances

Infusion Center Greeter

Emergency Department

Clerical

Please Indicate your Availability

Morning(Required)

Select all that apply

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Afternoon(Required)

Select all that apply

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Emergency Contact Information

Name(Required)

First Last

Phone(Required)

Relationship to Applicant(Required)

Character References

Please list two references, professional and/or personal, excluding family members. Make certain to notify these individuals that they will be contacted to provide information.

Name(Required)

First Last

Relationship to Applicant(Required)

Email(Required)

Phone(Required)

Name(Required)

First Last

Relationship to Applicant(Required)

Email(Required)

Phone(Required)

Upload a PDF your resume(Required)

Accepted file types: pdf, Max. file size: 10 MB.

Health Information

Physician Name

First Last

Phone

Medical Alerts

Have you ever been convicted of a crime (other than a minor traffic violation) in a court of law?(Required)

Yes

A conviction record will not necessarily prohibit you from volunteering.

If yes, please provide details below.

Confidentiality Statement

The Health Insurance Portability and Accountability Act (HIPAA), from a Federal law perspective, governs the use, access, and disclosure of protected health information by Nuvance health staff and volunteers. It is the responsibility of Northern Dutchess Hospital and all of its employees and volunteers to protect the confidentiality of medical records and privacy of all patients. The patient has a legal right to privacy concerning medical records, etc. It is the obligation of NDH to uphold the right. No employee or volunteer may violate confidentiality, based on state and federal laws or acts. You are to hold all information about patients in the strictest confidence. You may not discuss patient information with other volunteers or with persons outside of the hospital. Persons found to be in violation of this policy will be subject to sanctions.

Photography/Videography Consent

I hereby permit and release to Northern Dutchess Hospital and its affiliates the use of pictures taken for the purpose of recruitment and publicity of the Northern Dutchess Hospital / Thompson House Volunteer Programs.

Statement of Application

All of the above statements are true, and the information and references provided may be investigated without liability of Northern Dutchess Hospital. If accepted to participate in the volunteer program, I agree to abide by the policies of the Volunteer Services Department of Northern Dutchess Hospital, and all other hospital mandates. I understand that if any of the statements in this application are found to be untrue, and/or I fail to comply with the stated requirements, I may be subject to immediate dismissal from the Northern Dutchess Hospital.