Noyes Health / Community Outreach / Caregiver Resources / Home Away From Home Respite Center / Student Volunteer/Intern Form Student Volunteer/Intern Form Applicant Information First Name: School Address: State (School): Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Address: State (Home): Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Number: ( ) - Second three digits Last four digits Major(s): Minor(s): Last Name: City (School): Zip Code (School): City (Home): Zip Code (Home): Email Address: Expected Graduation Date: Select your availability (check all that apply): TuesdayThursday I can serve full time (9:30-2:15) on the day(s) selected above: YesNo If "No," please indicate your availability: Volunteer/Work Experience List most recent first. Name of Employer: Supervisor: Dates Worked: Title/Responsibilities: Name of Employer: Supervisor: Dates Worked: Title/Responsibilities: Name of Employer: Supervisor: Dates Worked: Title/Responsibilities: References Must be someone you have known for at least a year and who is not a relative. Please include at least one professional reference (co-worker, supervisor, etc.) Name: Address: Phone: ( ) - Second three digits Last four digits Email: Relationship: Name: Address: Phone: ( ) - Second three digits Last four digits Email: Relationship: Name: Address: Phone: ( ) - Second three digits Last four digits Email: Relationship: Additional Information Have you ever been convicted of a felony?: YesNo Do you have experience working with older adults? If not, that does not mean you cannot volunteer. We would just like to know about your experiences, if any: YesNo If "Yes," please explain: Tell about a significant experience you have had with an older adult and how that has inspired you to apply to become a volunteer/intern for the Home Away From Home Respite Center: What are you hoping to accomplish through this volunteer/internship opportunity? Please be specific: How did you hear about our program?: For Intern Applicants ONLY SUNY Geneseo faculty/staff internship coordinator: Number of credits requested for internship (Must be at least 1 credit. Each credit = 40 hours): Will this credit go towards your major/minor?: YesNo I hereby authorize UR | Noyes Health, the Home Away from Home Respite Center, and its affiliates, to use and release photos and/or videos of me taken in the course of the program for promotional and marketing purposes: YesNo By submitting this form, I affirm that the information on this application is true and accurate. I also understand that volunteering is contingent upon completing the required training.