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Volunteer Application Form

Niagara Lutheran
Health System

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

Download the Application Form

Step 1 of 9

11%

Online Volunteer Registration

Preferred Site (may choose more than one)(Required)

GreenField Health &
Rehabilitation Center Skilled Nursing & Rehabilitation
5949 Broadway

GreenField Manor/Court Independent/Assisted Living
5953/5951 Broadway

GreenField Terrace Enhanced Assisted/Memory Care
5979 Broadway

Name(Required)

First Last

Date

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Email(Required)

Cultural Information - Optional Question (for statistical purposes only)

White/Caucasian

Black/African-american

Native Hawaiian/other islander

Spanish/Hispanic/Latino

American Indian/Alaskan Native

Other

How did you find out about The GreenFields?

Do you have any volunteer experience?(Required)

No

Yes

Please describe your volunteer experience.

List any hobbies, special interests or skills you have or would like to share with our residents:

Are any of the residents, volunteers or staff members - friends or relatives of yours?

No

Yes

If yes, please list them and their relationship to you:

Do you have any physical or medical limitations that would affect your ability to complete certain tasks?

No

Yes

Please explain your physical or medical limitations:

Have you ever been convicted of a crime?

No

Yes

Please provide details of the conviction(s):

Would you please share with us?

Name of Church

Priest/Minister/Rabbi

Address

Street Address

In the event of an emergency, please notify:

Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many hours would you like to Volunteer at The GreenFields?

Mornings

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Afternoons

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Evenings

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Please indicate service areas which you are most interested in serving (may chose more than one):

Visiting, reading, writing, walks with Residents

Worship services

Outings

Clerical (specify below)

Sewing/mending

Transporting Residents for therapy

Transporting Residents to activities/outings

Assisting the hairdresser

Assisting in resident activities

Gift Shop/Café

Other (specify)

Please indicate which resident activities you would prefer:

Evening Activities

Outings

Bingo/Jeopardy

Other (specify)

I hereby sign that all the above information is true and accurate. Any false information will result in termination of my volunteer services.

Name

First Last

Date

MM slash DD slash YYYY

CAPTCHA

As a volunteer you are eligible for:

Free meals from the GHRC employee cafeteria if you work during meal times
Free flu shots during flu season & Yearly Health Assessment and PPD Series
Volunteer name badge
Invitation to the Annual Volunteer Appreciation Luncheon
The opportunity to join the Niagara Lutheran Health System Guild (minimal annual donation)
The fulfillment of helping others!

Any questions?
Contact: Mary Dumke, Development & Volunteer Coordinator
(716) 684-0202, ext. 1802 or email: mdumke@niagaralutheran.org

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admission application

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The GreenFields resident

5959 Broadway
Lancaster, NY 14086

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Become a Member of The Gem Society

The Niagara Lutheran Health System does not discriminate in the admittance of residents or the hiring of employees relative to age, race, creed, color, national origin, sex, sexual orientation, sexual preference gender, gender identity, blindness, handicap, sponsor, marital status, or religion.

Niagara Lutheran Health Foundation

Foundation Page

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