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Volunteer Application

Energize your Life! Become a Unity Health System volunteer today and join a very special team. Fill out the form below and click "Submit" to have a representative contact you with additional information about the wonderful volunteer opportunities that are waiting for you at Unity Health System! Or, call us at (585) 723-7101.

Please fill out the following information:
* indicates required information.

At which location are you interested in Volunteering?
St. Mary's Campus    Edna Tina Wilson Living Center   Unity Hospital Campus   No preferences/not sure

Name *
Gender * Male    Female
Street address *
City * State * Zip *
Phone * Home:     Work:     Cell:
Emergency phone Home:     Work:     Cell:
E-mail address
Birth date * (Example: 3/14/1985)

High school

WORK EXPERIENCE (Please include any volunteer experience)
(You can only upload MS Word, MS Excel, Text, RTF, and PDF files)
Why do you want to volunteer?
How did you hear about our volunteer program?
Time you have available for volunteer work:
Hours per week
Preferred days/time?

Please list the names, addresses, and telephone numbers of at least two (2) people who can vouch for your reputation, character, and work record, and who have known you for at least one year. One of these should be a work reference (if applicable).
Contact One
Name *
Phone *
Email address
Address *
Relationship to you *
Contact Two
Name *
Phone *
Email address
Address *
Relationship to you *
Have you ever been convicted of a crime? * Yes     No
If so, please describe fully the conviction(s) listing the nature of the offense(s), your age at the time of the offense(s), and your rehabilitation since the conviction(s).
(Record of convictions will not necessarily be a deterrent to doing volunteer work)
Conviction records *

  1. I understand the acceptance to volunteer will be on a 3 month introductory basis.
  2. If accepted for a volunteer assignment with Unity Health System, I agree to abide by Unity’s rules and regulations.
  3. The information contained in this application is complete and true to the best of my knowledge.
  4. Any misrepresentation or omission of facts will be cause for immediate dismissal.
  5. I authorize Unity Health System to contact any references for full information.
  6. I agree to have a health assessment at Unity’s Employee Health office if I am offered a volunteer assignment, and ANNUALLY THEREAFTER.
  7. I understand that my volunteer assignment is entered into voluntarily and that I am free to resign at anytime, and that Unity Health System may terminate the volunteer relationship at any time whenever it is in the best interest of Unity to do so.
  8. I understand that no management representative has any authority to enter into any agreement for volunteer work which is contrary to the conditions listed above.
  9. I understand that as a volunteer, I will be expected to observe confidentiality with respect to all information I may possess regarding my interactions with Unity Health System, its clients, patients, residents, and staff, and any knowledge of the contents of confidential records. Failure to adhere to this agreement is grounds for immediate dismissal. I also agree to maintain confidentiality after I leave Unity Health System for whatever reason.
  10. I hereby authorize Unity Health System to obtain personal reference, criminal record and CNA registry checks.
  11. By submitting this form, I hereby certify that all of the information submitted is true, accurate and complete.

Unity Health System is an Equal Opportunity Organization and complies fully with Federal and New York State laws prohibiting discrimination because of sex, age, color, creed, marital status, nationality or origin, ancestry, availability for military service, disability, or any other characteristic protected by federal, state, or local law.