Children's Hospital of Michigan- Volunteer Application

Application date

Please be aware that your application is NOT complete until you download the forms available on our webpage, have your physician fill them out, and email them to us at volunteerservices@stonybrookmedicine.edu When sending us emails, please include your name and date of birth in the subject line.

Are you a Junior Volunteer (between the ages of 14 and 17)?

Are you a Senior Volunteer (18 and over)?

Are you a Stony Brook University Student?

ATTENTION STONY BROOK STUDENTS: Please list campus address here

If you have a Stony Brook ID Number, please enter it here

Have you volunteered with us previously?

If you have ever been issued a Stony Brook ID#, please enter your ID# here

* Legal Family/last name

* Legal First name

Middle name

Please provide any previous legal names used

Gender

* DOB

* Home Address

Line 2

* City

* State

* Zip/postal

* E-mail

Phone (Home)

* Phone (Mobile)

Volunteer Experience?

Are you currently employed? Please check box if yes

Current Employer

Have you ever been convicted of a felony or misdemeanor?

If yes, please provide date, charge and disposition. Please also provide where it occurred (town and state)

Please provide three written reference letters. The letters should be sent in AFTER your application is accepted. They should be emailed to us at volunteerservices@stonybrookmedicine.edu Make sure your name and date of birth appear in the subject line. A fillable reference letter template is available on our website under the "Forms" section for your convenience. NOTE: If you are a returning volunteer, the references are waived.

How did you hear about the volunteer program here at Stony Brook?

* By checking this box, I understand this is not an application for an internship, shadowing or research assignment.

I have read through the available assignments and have found many that are of interest. I understand that this is an application to an assignment in general and no guarantee that you will be placed in a specific assignment

I understand that if there is only one assignment that meets my interest, I must reach out to the department supervisor to discuss availability and acceptance. 

Attention Applicant: Please be advised that Stony Brook University Hospital Volunteer Services does background checks on all new hires. Prior criminal conviction may not prevent you from getting the volunteer position. However, falsifying your volunteer application is grounds for withdrawal of a volunteer job offer or termination.

* ACKNOWLEDGEMENT & AUTHORIZATION
By checking the box, I hereby affirm that this application and all documents submitted to me in connection with my application for volunteering contain no willful misrepresentations and that the information given by me is true and complete. I understand that any false statements or misleading omissions made by me in connection with my application, or in responding to any requests for information, can be sufficient ground for my rejection as a candidate for volunteering or for my immediate termination and/or referral for criminal prosecution. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying documents if any) to provide any relevant information that may be needed to arrive at a decision of acceptance into the volunteer program.
By checking the box, I agree if accepted as a volunteer to abide by all rules, policies and regulations of Stony Brook University. I certify that the information that I have provided is complete and accurate. 

* In connection with my application to become a volunteer at the Stony Brook University Hospital, hereafter 'employer', I hereby authorize the employer to conduct a background investigation pursuant to the Fair Credit Reporting Act which may include, but not limited to, a Social Security Number verification and Criminal Conviction verification. I also authorize employer to conduct an Office of the Inspector General (OIG) search to ascertain my current status with the OIG List of Sanctioned Individuals, and to conduct a General Services Administration (GSA) search of their List of Parties Excluded to ascertain my current status in the GSA.
I am aware that I have the right under the Fair Credit Reporting Act to request from the vendor performing the background check, the nature and scope of any report they have prepared in conjunction with the verifications conducted related to my application to volunteer. I authorize and request all courts and law enforcement agencies to release such information without restriction or qualification. You may ask for a copy of this background check when submitting your application.
By checking the box you consent and hereby release Stony Brook University, Stony Brook University Hospital, their respective officers, employees and agents, from any liability and responsibility arising from preparation of the background check, investigation or report, and any resulting outcome or consequences, as well as any liability and responsibility arising from obtaining, reviewing, discussing any information gathered in connection with a review of my application, and any resulting consequences. 

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