Physical Therapy Department

Occupational Therapy Department

VOLUNTEER APPLICATION

Date: 2/15/2014
Last Name: __Hall___________________ First Name____Ashley____________________
Date of Birth: ____12/03/1992__

Age: 21_

Gender: M

Street 1:________1113 east 58th st

____________________________________________________________
Street 2: ____________________________________________________________________
City: ______ Brooklyn________________________________ State: _NY_____
Home Phone: ______________________

Zip: _11234

Work Phone: ______________________

Cell Phone: __347-701-7152_____________________

Email: _ah714@hunter.cuny.edu_
Please check off all that apply:
Employed (Full or part time)
Under 16 years of age

Self-employed/freelance
Student (Full or part time)

Are you authorized to work or study legally in the United States?

Unemployed
Retired
16 or 17 years of age
Yes

No

Highest Level of Education Completed:

Associates Degree
Bachelors Degree
Doctoral Degree
GED
High School
Masters Degree
Military
Some College
Vocational/Trade School
Other*
*If other, please specify: _________________________________________________________
Summer Only Applicant: Yes

No

Current School: _Cuny- Hunter College

Expected degree:_Bachelor of Arts________________

Expected Graduation date:_June 2016

Employer: _____________________________________________________________________
Employer Address:
________________________________________________________________________
______________________________________________________________________________

Availability
Can you make a 120hour commitment to volunteer at NYU Langone Medical Center at the same day and
time every week?
Yes, I can make a weekly commitment for:

No, I cannot make a weekly commitment for 6 or 12

months but

6 Months

I can commit to: ________ months.

12 months

Please circle the days and write in the times for each day you are available to volunteer, the same day &
time, each week.
Example:

Wednesday

Thursday

10 am 2 pm
Days: Monday

Tuesday

Hours: ______

__10am-3pm_

Friday
6 10 pm____

Wednesday
_10am-3pm

Saturday

Sunday

8 am 10 pm

Thursday

Friday

__________

________

________

Saturday

Sunday

________ _______

Language(s) spoken and/or written other than English

_______________________________________________________________________________

Emergency contact information:

Name: ____Vashti Hall

Relationship ____Mother_________________________________________________________________

Home Phone: ______________________

Work Phone: ______________________

Cell Phone: ___(917)_742-1134___________________

Email: _______________________________________________________________________

Reference
Please provide a reference letter from the contact person below (CANNOT BE A RELATIVE)
Name: __Deborah Parker ____________
Address: ______________________________________________________________________
______________________________________________________________________________
Relationship __She is the director of the Womens resource center at the Borough of Manhattan
Community College. ________
Home Phone: ______________________

Work Phone: __(212) 220-8165 ___

Cell Phone: _______________________

Email: doparker@bmcc.cuny.edu_____
Volunteer Experience
Please list your most recent volunteer experience:
Name of organization ____Coney Island Hospital _________
Volunteer Dates: From _February 2009 to November 2009__________
Name of supervisor and phone # _Misty Teitel (Director) 718-616-3161 ___
Please describe volunteer duties: _Deliver specimens to the appropriate lab, assist the Nurse as needed,
greet visitors/ direct visitors, manage front desk, stock medical supplies.
Have you ever volunteered at NYU Langone Medical Center before?

No

Yes

If Yes, when? ____________________________________________________________________

Questions:
PLEASE NOTE: YOUR APPLICATION WILL NOT BE CONSIDERED UNLESS ALL
QUESTIONS ARE COMPLETED.
Why would you like to volunteer at NYU Langone Medical Centers Physical Therapy/Occupational
Therapy Department?What do you hope to gain from this experience?
I believe that the NYU Langone Medical Centers PT/OT department will provide me with the best
experience and knowledge about the field. I hope to gain a better firsthand understanding of physical and
occupational therapy and stronger interest in the field, I also hope to learn ways to take the career of
Physical therapy/Occupational therapy further.
List and explain any additional volunteer experience you have had in a hospital, medical center or
doctors office related to Physical Therapy/Occupational Therapy
_I have volunteered at Coney Island Hospital but the position was not related to Physical
Therapy/Occupational Therapy. _
Have you ever been convicted of a crime? If so, please specify nature, date of conviction and penalty.
__No.______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are you required to volunteer? (i.e. court mandate, school requirements, college coursework, etc.) Please
document specific information for this requirement.
___I am interested in going into the field of either Occupational Therapy or Physical Therapy. Some of
the programs require that I have Volunteer experience in the field before I can apply to either program. I
am also not sure if I would like to pursue a career in Occupational therapy or Physical Therapy. So this
would be a great decision making experience.____________________________
Certification of Application
I understand and agree that submitting this application form does not automatically register me as a
volunteer at NYU Langone Medical Center. I am aware there are certain qualifications I must meet
including orientation, medical clearance, background check and a 120 hour commitment. By submitting
this form, I attest that the information I have provided on the form is true, accurate and NOT provided by
a third party.
Name

Ashley Hall

Date 2/15/2014 ___________