SAVI 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:

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

What is your primary 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 QUALIFICIATIONS

Skills

* What motivates you to become a SAVI Advocate 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 would serve.

* How might volunteering at SAVI fit into your life?

* What experiences do you have related to SAVI's services or populations?

* How did you learn about SAVI?

* What expectations do you have for the Advocate training?

* Please share some personal or professional qualifications or experiences that have prepared you to support survivors of sexual or intimate partner violence in a hospital setting.

SAVI Requirements

21 years of age or older at the time of interview.
Active residency in Manhattan, Queens or Brooklyn, to be close to the hospitals we serve. (Some areas of these boroughs are out of our catchment area this is based on zip code)
Completion of a phone or video interview.
Ability to attend all sessions (both online and in person*) of the 40-hour NYS Department of Health Training (see below for more information) provided by SAVI.
Willing to commit to a minimum of three shifts per month, for at least one year. Shift times are as follows: midnight - 6am; 6am - noon; noon -6pm; 6pm - midnight

*SAVI recognizes the current constraints due to COVID-19 and any in person meeting would be within the recommended guidelines for maximum number of people allowed, social distancing and facial masks/coverings

* What days/times are you available to volunteer? Please select all that apply.

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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Signature

SAVI Volunteer Application

Please complete all required fields highlighted in yellow.

PERSONAL INFORMATION

If you are an International Applicant, please fill out:

EDUCATION

High School

College/University

Additional Education

RESUME

EMERGENCY CONTACT

CONNECTIONS TO MOUNT SINAI

MORE ABOUT YOU

OTHER SPECIAL SKILLS OR QUALIFICIATIONS

REFERENCES

Reference #1

Reference #2

Reference #3

AGREEMENT