Student Intern/Rotator Application

PERSONAL INFORMATION

* First

Middle

* Last

Preferred Name

* Address

Apt. #

* City/Town

State

* Zip

* Cell Phone Number

Home Phone Number

Preferred phone type

* Personal E-mail (non-school email address)

Gender

Please indicate your preferred pronoun(s):

Age: (all Mount Sinai applicants must be at least 18 years old)

* Date of Birth

Have you ever been suspended or discharged by an employer for incidence of physical or verbal abuse of a patient, co-worker, customer or visitor?

* If yes, please explain.

Are you currently a U.S. Citizen or Green Card holder?

If yes, which one?

If you are neither a U.S. Citizen nor Green Card holder, you will need clearance from the Mount Sinai International Personnel (IP) Department prior to being placed as a volunteer.

If you are an International Applicant, please fill out:

* Name of Department Administrator

* Name of Supervisor

* Location of Internship

* Volunteer Assignment Start Date

* Volunteer Assignment End Date

CPT Approved?

* Please note for foreign nationals only, upload your proof of CPT.

EDUCATION

College/University

Please indicate highest level degree.

* Name of School:

School Address:

Major:

* Type of Degree:

Degree status:

* Graduation Date (or Anticipated Graduation Date)

Additional Education

School

Certification/License/Degree:

RESUME

* Please upload a copy of your resume.

EMERGENCY CONTACT

* IN CASE OF EMERGENCY, WHOM SHOULD WE CONTACT? Name:

* Relationship:

* Phone:

CONNECTIONS TO MOUNT SINAI

How did you learn about our Department of Volunteer Services? Please check all that apply.

If other, please specify

Have you ever volunteered at the Mount Sinai Health System?

* If yes, dates:

Mount Sinai Health System Site:

* Program/Department

* Supervisor

Are you a current or previous employee of Mount Sinai Health System?

Are you a previous employee or retired?

MSHS Site

Department

If Other, please describe

* Position/Title

* Supervisor

Are you a current or previous student of Icahn School of Medicine at Mount Sinai (ISMMS)?

Please indicate which, previous or current:

If Sinai Student, Degree program

Do you have any relatives employed by The Mount Sinai Health System?

If yes, please provide name of your relative and how they are connected to Mount Sinai.

Internship/Externship/Rotation Information:

* School:

* Program:

Please select the length of your assignment.

* Start Date

* End Date

* Name of Supervisor at Mount Sinai

* Email of Supervisor at Mount Sinai

AGREEMENT

I understand and agree that:

I certify that the information contained in this application is correct to the best of my knowledge. I authorize investigation of all matters contained in this application and agree that any misleading or false statements could be cause for rejection of this application or would be sufficient cause for dismissal from a volunteer placement at the Mount Sinai Hospital. I understand that my volunteer placement is contingent upon satisfactory completion of a toxicology screening and a health screening by a Mount Sinai Employee Health Service practitioner or private physician, the receipt by Mount Sinai of a satisfactory reference and my satisfactory completion of the probation period. I hereby authorize my present/past employers to furnish Mount Sinai with my records of service.
If I am accepted as a volunteer, I authorize Mount Sinai Hospital to conduct any and all verifications as permitted by Federal, State and municipal codes and regulations. I agree to abide by all Mount Sinai rules and regulations. I agree to follow Mount Sinai policies with respect to a drug-free workplace and I affirm that I do not use un-prescribed controlled substances and/or any illegal substances. I understand that my volunteer service is not governed by any written or oral contract and is considered an "at will" arrangement. This means that I am free, as is Mount Sinai, to terminate the volunteer relationship for any or no reason, as long as there is no violation of applicable Federal, State or Local law.
I understand that the volunteer clearance process is highly selective and that the completion of the volunteer application does not guarantee a volunteer placement at Mount Sinai Health System. In consideration of any volunteer opportunity which may be offered to me, I agree to comply with the policies, rules, regulations and procedures of Mount Sinai. This application will remain current for 90 days. If I have not then been on boarded as a volunteer by Mount Sinai within this timeframe, I understand that I may need submit a new application to remain eligible for volunteer consideration.

My name below will stand as my signature, confirming the completeness and accuracy of the information I provided above, and will carry the same force and effect as if it were signed and affixed by my hand.

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Signature