Domestic (US Citizen or Green Card Holder) Observer Application

** Please DO NOT COMPLETE THIS APPLICATION until you receive a notification from the Mount Sinai Department of Volunteer Services (observers@mountsinai.org), which we anticipate you will receive shortly. This will expedite the processing of your application. Thank you for your cooperation. **

Please complete all required fields highlighted in yellow.

New User Details

User ID

User ID (verify)

Password

Password (verify)

PERSONAL INFORMATION

* First

Middle

* Last

Preferred Name

* Address

Apt. #

* City/Town

State

* Zip

* Cell Phone Number

Home Phone Number

Preferred phone type

Gender

Please indicate your preferred pronoun(s):

Age: (all Mount Sinai observers 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 to complete a Foreign National Observer Application.

EDUCATION

High School

Are you a current high school student?

High School Name

High School Address

Current Grade

College/University

Please indicate highest level degree.

Name of School:

School Address:

Major:

Type of Degree:

Degree Status:

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.

MORE ABOUT YOU

Please note: all observerships must be arranged and approved by a physician or other healthcare provider before submitting your application.

Are you employed in a healthcare environment OR a student over the age of 18 and enrolled in at least an undergraduate program?

If yes, which one?

* Mount Sinai Supervisor Name

* Mount Sinai Supervisor or Department Administrative Coordinator Email

* Mount Sinai Department

Will your observership take place in the main operating room/major procedural areas (e.g., cardiac catheterization, electrophysiology, endoscopy, interventional radiology)?

If yes, where will you be observing?

Please select the length of your obersvership.

* Please select the Mount Sinai Health System site where you will be observing.

* Expected Start Date:

* End Date:

AGREEMENT

I agree to abide by the rules and regulations of the Mount Sinai Medical Center observership progrm.
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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