Noyes Health / Community Outreach / Caregiver Resources / Home Away From Home Respite Center / Student Volunteer/Intern Form Student Volunteer/Intern Form place field "FirstName" below Applicant Information First Name place field "SchoolAddress" below School Address place field "SchoolState" below State (School) place field "HomeAddress" below Home Address place field "HomeState" below State (Home) place field "PhoneNumber" below Phone Number place field "Major" below Major(s) place field "Minor" below Minor(s) place field "GPA" below place field "LastName" below Last Name place field "SchoolCity" below City (School) place field "SchoolZipCode" below Zip Code (School) place field "HomeCity" below City (Home) place field "HomeZipCode" below Zip Code (Home) place field "EmailAddress" below Email Address place field "GradDate" below Expected Graduation Date place field "MajorGPA" below place field "Availability" below Select your availability (check all that apply) Tuesday Thursday place field "HoursAvail" below I can serve full time (9:30-2:15) on the day(s) selected above: Yes No place field "OtherAvailability" below If "No," please indicate your availability place field "EmployerName1" below Volunteer/Work Experience List most recent first. Name of Employer place field "Supervisor1" below Supervisor place field "DatesWorked1" below Dates Worked place field "Title1" below Title/Responsibilities place field "EmployerName2" below Name of Employer place field "Supervisor2" below Supervisor place field "DatesWorked2" below Dates Worked place field "Title2" below Title/Responsibilities place field "EmployerName3" below Name of Employer place field "Supervisor3" below Supervisor place field "DatesWorked3" below Dates Worked place field "Title3" below Title/Responsibilities place field "ProfessRefName" below 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 place field "ProfessRefAddress" below Address place field "ProfessRefPhone" below Phone place field "ProfessRefEmail" below Email place field "ProfessRefRelationship" below Relationship place field "ProfessRefName2" below Name place field "ProfessRefAddress2" below Address place field "ProfessRefPhone2" below Phone place field "ProfessRefEmail2" below Email place field "ProfessRefRelationship2" below Relationship place field "ProfessRefName3" below Name place field "ProfessRefAddress3" below Address place field "ProfessRefPhone3" below Phone place field "ProfessRefEmail3" below Email place field "ProfessRefRelationship3" below Relationship place field "HasConviction" below Additional Information Have you ever been convicted of a felony? Yes No place field "ExperienceSeniors" below 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 Yes No place field "ExpExplain" below If "Yes," please explain place field "SignificantExperience" below 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 place field "Accomplish" below What are you hoping to accomplish through this volunteer/internship opportunity? Please be specific place field "HowRefer" below How did you hear about our program? place field "FacultyStaffName" below For Intern Applicants ONLY SUNY Geneseo faculty/staff internship coordinator place field "NumberofCredits" below Number of credits requested for internship (Must be at least 1 credit. Each credit = 40 hours) place field "TowardMajorMinor" below Will this credit go towards your major/minor? Yes No place field "PhotoRelease" below 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 Yes No 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. $$submit-button$$
