Emergency Department Academic Associate Research Volunteer Application Form

Personal












Prior Affiliation with SUNY Upstate:
         If Yes,
Emergency Contact






Employment Information
Are you: (please check all that apply)





Education/Training Information






Previous Health-Related Experience


Were you paid?
Were you a volunteer?


Were you paid?
Were you a volunteer?


Were you paid?
Were you a volunteer?
Language (Other Than English) ProficiencyPlease enter languages and check appropriate boxes (multiple boxes can be checked):

Proficiency:

Proficiency:

Proficiency:

RecommendationsPlease provide two recommendations from non-family members who can discuss your suitability to volunteering in a hospital setting. Send them the url: http://www.upstate.edu/hospital/volunteers/ed_research_volunteer/ and they can download the recommendation form from the right column, complete the form online and e-mail to wojciks@upstate.edu directly. Provide the contact information for the recommendation to assure that they are tracked with your application:










Required AttachmentsEssay:
Curriculum Vitae: Please attach/upload your Curriculum Vitae (MS Word or PDF):






I submit my name for consideration to volunteer at University Hospital. I understand that, ideally my association as a volunteer will extend far into the future, but a commitment of at least 100 hours is expected during the first 6 months of service. In addition, the college volunteer program is based on a per semester basis and requires a 50 hour commitment per semester.

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