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Volunteer Application Form

Niagara Lutheran
Health System

5949 – 5979 Broadway,
Lancaster, NY 14086,
Fax: (716) 206-0484

VOLUNTEER APPLICATION FORM
Which facility/facilities are you interested in volunteering at?
- GF TERRACE
- GHRC
- GF MANOR/COURT
- FOUNDATION
Name*
First Last
Date:*
Date Format: MM slash DD slash YYYY
Address:
Street Address
City/State/Zip:
Home Number:
Cell Number:
Email Address:
Other Contact:
Are you 16 years of age or older?
- Yes
- No
1. Which day(s) of the week would be the most convenient for you to volunteer?
- Mon AM
- Mon PM
- Tues AM
- Tues PM
- Wed AM
- Wed PM
- Thurs AM
- Thurs PM
- Fri AM
- Fri PM
- Sat AM
- Sat PM
- Sun AM
- Sun PM
2. Do you have any physical or medical limitations that would affect your ability to complete certain tasks?
- Yes
- No
Please explain:
3. Please indicate areas you are most interested in:
- Filing
- Visiting, reading and writing for residents
- Computer work
- Transporting residents for therapy
- Assisting with worship services
- Transporting residents to activities
- Assisting the hairdresser
- Sewing/mending
- Assisting in resident activities
- Sorting/distributing mail
- Gift shop/cafe
Other (please indicate details):
4. If you listed “Assisting in resident activities," please indicate which activities you would prefer:
- Evening activities
- Entertainment programs
- Discussion group
- Outings
- Morning coffee and doughnuts
- Bingo
- Residents’ restaurant
- Worship services
5. Do you have any volunteer or work experience in the health care field?
- Yes
- No
Please List:
6. List any hobbies, special interests or skills you have or would like to share with our residents:
7. Are any of the residents, volunteers or staff members friends or relatives of yours?
- Yes
- No
If so, please list them and their relationship to you.
8. In the event of an emergency, please notify:
Name:
Phone:
Address:
Street Address
Relationship:
9. Have you ever been convicted of a crime?
- Yes
- No
If yes, please give details.
10. Comments:
11. Would you please share your religious affiliation with us?
Name of Church:
Religion:
Address:
Street Address
City/State/Zip:
Priest/Minister/Rabbi:
Thank you! We look forward to having you join us!
As a volunteer you are eligible for:
- Free meals from the employee cafeteria if you work during meal times (only at GHRC)
- Free flu shots when available
- Your name badge
- Invitation to the volunteer appreciation luncheon
- A yearly check-up and PPD test
- The opportunity to join the Niagara Lutheran Health System Guild (minimal annual donation)
- The fulfillment of helping someone else

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Niagara Lutheran
Health System

716.684.8400

5959 Broadway
Lancaster, NY 14086

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