Volunteer Application Form

Requirements:

Active or retired Nursing Assistant, Licensed Practical Nurse, Registered Nurse, Nurse Practitioner willing to volunteer time to serve at a colleagues memorial service.

Guard Attire:

**Please note you are responsbile for the below guard attire**

White uniform- scrubs acceptable

White shoes- (no crocs)

White nurses cap- can be found on Amazon.

Guard cape- navy blue outside, red inside ( you have the option to get the cape made yourself or you can pay $120 we can get it made for you)

White candle- LED

Your Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Heathcare Role*

Are you a Northwell Health Team Member Alumni?

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Area you are willing to cover?*

	Select One or More
Brooklyn
Bronx
Queens
Manhattan

Why do you want to be a volunteer in this program?*

Please tell us your other volunteering experiences.*

Your Consent

I, the undersigned, give my consent for the publication of identifiable details, which can include photograph(s) and/or videos and/or case history and/or details within the text (“Material”) to be published on our Organization's social media, and or website.I, the undersigned, I do not give my consent for the publication of identifiable details, which can include photograph(s) and/or videos and/or case history and/or details within the text (“Material”) to be published on our Organization's social media, and or website.