Welcome to the Friends of Strong Volunteer program!

Summer High School Application

Personal Information

* Application Entry Date

* First Name

* MI

* Last Name

* Home Address

* City

* State

* Zip Code

* Student Phone Including Area Code (example: 5852752420)

* Student E-mail Address

* DOB (example: 02/09/1969)

What is your gender?

Shirt Size

Name of High School

Class of

Emergency Contact Information

* Parent or Guardian Contact Name

Parent or Guardian City

Parent or Guardian State

* Parent or Guardian Emergency Phone Including Area Code

* Parent or Guardian E-mail

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that all volunteers must folllow New York State regulations for initial immunization screening and complete the required hospital orientation and update both annually. I understand that all information I may gain, directlly or indirectly, concerning a patient, physician, or any other person is to be kept confidential. Failure to do so may result in termination of my volunteer position. I understand, if any of the information on this application has been falsified, or if informaiton has been omitted, the Friends of Strong reserve the right to rescind any offer made through their program. I understand that as a Friends of Strong volunteer I am donating my time and efforts to UR Medicine and will not be paid for my services.

In typing my name below, I understand and accept the above statements.

* Signature/Date

FOR OFFICE USE ONLY

Day

Shift

Interviewer

EH Appt

Not Placed

Job Training