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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 8

12%

Online Volunteer Application

Preferred Site (may choose more than one)

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

Alias or Maiden Name

Date

MM slash DD slash YYYY

Address(Required)

City State / Province / Region

Address (cont.)

Street Address Address Line 2 ZIP / Postal Code Country

Home Phone(Required)

Cell Phone

Work Phone

Email(Required)

16 years of age or older?(Required)

Yes

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?

Yes

Please explain where:

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?

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?

Yes

Please explain:

Have you ever been convicted of a crime?

Yes

If yes, please provide details:

All new volunteers will undergo a required background check, including fingerprinting, covered by The GreenFields.

In the event of an emergency, please notify the following:

Name

Phone

Address

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

Relationship

How many hours a week would you like to volunteer at The GreenFields?

Which day(s) / time(s) of the week would be the most convenient for you to volunteer?

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 the areas in which you are most interested in serving (may choose more than one):

Visiting, reading, writing, walks with residents

Transporting residents for therapy

Assisting with worship services

Transporting residents to activities/outings

Accompany residents on outings

Transporting residents to the on-site hairdresser

Multi-media music & story capturing

Clerical support (specify below)

Assisting in resident activities

Sewing/mending

Gift Shop/Café

Other

Other (specify)

Are you affiliated with any church?

Yes

If so, which church:

Specify clerical support

If you listed “Assisting in resident activities”, please indicate which activities you would prefer:

Evening activities

Off-site outings

Bingo/Jeopardy

Other (specify):

Other (specify)

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

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

CAPTCHA

As a volunteer you are eligible for:

Free flu shots during flu season & Yearly Health Assessment and PPD Series
Volunteer name badge
Volunteer appreciation & recognition
The opportunity to join the Niagara Lutheran Health System Guild (minimal annual donation)
The fulfillment of helping others!

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

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admission application

5959 Broadway
Lancaster, NY 14086

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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.