Research Volunteer Application

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 applicants must be at least 15 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

High School

Are you a current high school student?

* School Name

* School Address

Current Year of Applicant:

* Name of School Advisor or Counselor

* Title

* Email

College/University

Please indicate highest level degree.

Name of School:

School Address:

Major:

Type of degree:

Degree status:

Will you be receiving academic credit for this volunteer experience?

* Please provide additional information about your Mount Sinai assignment that for which you will receive academic credit at your home institution. For example, is the assignment part of a formal school program (e.g., a required rotation or clinical experience), OR is it more of an informal experience, such as an independent study, class requirement, elective, etc.?

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?

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

If you are a previous Mount Sinai volutneer, please provide the dates you volunteered.

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

Thank you for your interest in becoming a Mount Sinai Research Volunteer. Due to program limitations, we are only able to accept applications from people who already have assignments with a Principal Investigator (PI) at this time. If you have not already secured a placement in a laboratory or as part of a clinical research team, then we are unable to process your application.

Do you have a confirmed volunteer placement?

Please select the length of volunteer assignment.

* Will your volunteer experience be onsite, remote or hybrid? (Select below)

* During your volunteer assignment, will you have access to Protected Health Information (PHI) and/or electronic access to Mount Sinai systems?

* Name of Supervisor at Mount Sinai

* Email of Supervisor at Mount Sinai

Department:

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

Will you receive payment, funding, or a stipend for this placement?

Will Mount Sinai provide the payment, funding, or a stipend?

If yes, please provide additional information about the stipend you are receiving from Mount Sinai (e.g., department issuing payment and amount).

Will you be working directly with animal tissue or live animals during your volunteer placement?

At any point during your volunteer assignment, will you be observering in the main operating room/major procedural areas (e.g., cardiac catheterization, electrophysiology, endoscopy, interventional radiology)?

If yes, where will you be observing?

* Please list all lab skills/techniques you have learned through a class or in a lab.

* Please list all relevant science, math, and computer science courses you have completed.

* If you have previous research experience, please share: 1) your PI and/or supervisor's name(s), 2) the institution where the research took place, 3) the start and end dates, 4) brief description of the project, and 5) your responsibilities and tasks. Please change to: If you have had previous research experience, please share: (1) the school or institution, (2) your PI/Supervisor, (3) beginning and end dates, (4) a brief description of the project, and 5) your tasks and responsibilities.

* Please select the research fields you are interested in. Check all that apply

* Please list all of the time commitments/extracurricular activities you will have outside of class during the time period you wish to volunteer.

What is your native language?

Do you speak any additional languages?

If so, which language(s)?

Have you participated in any youth education and pipeline programs sponsored by the Icahn School of Medicine at Mount Sinai (ISMMS)? 

* Which program(s) have you participated in?

Are you a current or previous participant?

OTHER SPECIAL SKILLS OR QUALIFICATIONS

Skills

* What motivates you to want to volunteer at this point in your life? Please indicate whether you have an interest in any particular program or patient population and share why.

* What skills and strengths would you bring to your volunteer service? Please share how these might impact your service and those you serve with.

* How might volunteering impact your career or professional goals?

* What experiences do you have related to where you want to volunteer?

* What days/times you are available to volunteer? Please be specific. Minimum of four consecutive hours per week. Please note that a majority of our opportunities are on Mondays through Fridays from 9 am to 5 pm.

REFERENCES

Reference #1

* Reference #1 name:

* Title

* Organization

Relationship

* E-mail

Reference #2

* Reference #2 name:

* Title

* Organization

Relationship

* E-mail

Reference #3

Reference #3 name:

Organization

Title

Relationship

E-mail

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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