Volunteer Requirements & Instructions
PROGRAM APPLICATION
Applications may be submitted during any month of the year and will be reviewed within 30 days. Adirondack
Health welcomes everyone, regardless of background or ability, to submit an application to join our Volunteer
Program. Adult volunteers contribute in many ways at our facility, providing therapeutic and emotional care and
friendly support to patients and their families. To qualify for the Volunteer Program, applicants must meet
following requirements:
• Must be at least 18 years old, in good health, & able to communicate well in English.
• Willing to wear provided AH attire
Step 1: Complete a volunteer application
Step 2: Selected applicants will be invited to interview with the Volunteer Coordinator.
Step 3: If selected, you’ll attend volunteer orientation, have a background check, complete online HIPAA
training, and schedule your volunteer shifts. Volunteers born after January 1, 1957, must provide a
copy of immunization or vaccination documents.
QUESTIONS: If you have any questions in regards to the Volunteer Program, please reach out to the Volunteer
Coordinator, Teri Stiles at 518-897-2413 or [email protected].
VOLUNTEER APPLICATION- REVISED 3/7/2023
Department of Volunteer Services Application
Today’s Date
Last Name First Name Middle Initial
Address City State Zip Code
Home Telephone Cell Telephone
E-mail Address
How did you hear about the Volunteer Services? Friend Media Ad
Have you ever been convicted (found guilty) of a crime (including probation(s) before judgment), or are there any
pending criminal charges awaiting a hearing in a court of law? Do not list any criminal charges for which records
have been expunged. Yes No
If you answered YES, please describe all convictions, when they occurred, the facts and circumstances involved, and
information pertaining to rehabilitation:
Volunteer Experience: (List most recent service positions, if any)
Position:
Agency:
Date:
VOLUNTEER APPLICATION- REVISED 3/7/2023
Placement Preferences: Indicate 1st ( ), 2nd ( ), and 3rd ( ) choice
1. Administrative and clerical duties
2. Gift Shop – stocking, cleaning, etc.
3. Volunteer Meet & Greet desk
4. Non-Clinical: clerical, running errands, answering phones
5. Nursing: assist nurses, interact with patients, and assist with meals, transport patients, learn sitter skills, greet
patients in lobby, ready rooms, activities on psych units
6. No One Dies Alone Program training
7. Pet Therapy Training
8. Other Interests include:
Our Special Volunteer programs
➢ NODA - No One Dies Alone is a program where volunteers can give the greatest kindness of sitting bedside
with patients during their final hours. Some patients or residents have outlived their families and friends, or
families are out of town and can't be there in time.
Volunteers go through special NODA training and are notified by email or phone call when a vigil or
companionship is needed for a lonely patient/resident. Our Comfort Room, on the third floor of the medical
center, was designed by nurses to offer comfort when patients are not able to go home to pass. Mercy Living
Center companionship occurs in the resident’s room.
➢ Healing Hounds - A pet therapy program where owners bring their dogs to visit patients to offer diversion
and comfort.
Responsibilities include: Visit patients and visitors accompanied by your certified therapy dog. You must own
your dog and receive visitation approval.
Dogs who participate in the pet therapy program meet the following requirements:
• Must be at least 1-year-old.
• Must have documentation of current vaccinations.
• Must have a documented yearly physical on file.
• Must be kept on a leash or in a pet carrier at all times when entering and traveling within facility.
Volunteer Handlers who participate in the therapy dog program meet the following requirements:
• Must carry liability insurance for their dog and have proof of insurance on file at the hospital.
• Complete health-related requirements and the required background check.
• Attend a General Volunteer Orientation without their animals before participating in pet therapy.
• Must wear the required volunteer uniform during their visits.
Adirondack Health has a policy and procedure that must followed regarding pet therapy and service dogs.
VOLUNTEER APPLICATION- REVISED 3/7/2023
Department of Volunteer Services
Pre-Interview Questions
Name: Date:
Please answer the following questions before attending your interview:
What attracted you to our volunteer program?
What would you like to get out of your volunteer experience/internship? What would make you feel like you have
been successful?
Have you ever volunteered? If yes, for what agency and what position?
Describe the agency and your volunteer responsibilities.
What have you enjoyed most about your previous volunteer position(s)?
What skills and qualities do you feel you have to contribute to Adirondack Health?
Are you willing to commit to the requirements of the Volunteer program?
VOLUNTEER APPLICATION- REVISED 3/7/2023
Department of Volunteer Services: References and Emergency Contact
Duration of Volunteer Services:
One Time: 1-3 months: More than 3 months: On-call:
References: List two people other than relatives who would be willing to serve as personal references.
Name Telephone Number
Street Address City State Zip Code
E-mail Address
Name Telephone Number
Street Address City State Zip Code
E-mail Address
Emergency Contact: In the event of an emergency, please list the person you would want notified.
Name Relationship
Home Telephone Number Business Telephone Number Cell Phone Number
Statement of Understanding:
I certify that all information is true and has been given voluntarily. I understand that this information may be disclosed to any
party with legal and proper interest. I release the agency from any liability whatsoever for supplying such information.
I understand that I must be at least 13 years of age to volunteer at Adirondack Health and if I am under the age of 18 years of
age and/or attending high school I will need parental consent.
Upon being offered a Volunteer position, I understand that I may be required to provide additional information pertinent to the
position for which applied.
Applicant’s Signature: Date:
VOLUNTEER APPLICATION- REVISED 3/7/2023
VOLUNTEER CONSENT FORM
I am engaged in or about to be engaged in a Volunteer program at Adirondack Health. I am aware that Adirondack Health does
not provide insurance coverage for volunteers if personally injured or if damage occurs to personal property while acting as a
Volunteer. I further understand that I am not entitled to Workers Compensation benefits, health insurance benefits, or any other
benefit available to employees of Adirondack Health. I agree that I will not hold Adirondack Health or its officers or agents thereof
liable for any injury sustained to person or property while I am acting in a volunteer capacity.
In connection with my activities as a volunteer, I agree to hold all information I may have access to about patients, residents or
former patients/residents confidential. Disclosure of such information to unauthorized persons is prohibited and will make me
subject to civil action for the collection of monetary damages and/or suspension or dismissal.
I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER:
I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a benefit as a result
of my services hereunder.
▪ I will observe all Adirondack Health regulations.
▪ I understand that texting is not allowed at any time while volunteering, as this does not create a professional impression.
▪ I understand that cell phone use is not permitted at any time while I am volunteering.
▪ I will endeavor to be prompt and regular in my services and I will perform my assigned volunteer duties to the best of my
ability.
▪ I understand that program placement depends upon the needs of Adirondack Health.
▪ Photos taken while participating as an Adirondack Health Volunteer or at special functions may be used for promotional
reasons (newsletters, brochures, pamphlets, etc.)
▪ I will adhere to Adirondack Health’s dress code.
▪ I understand that if I am sick and need to be absent from my Volunteer assignment, that I contact the Volunteer Coordinator.
I understand that the training dates are offered periodically and that I must attend prior to the start of the program and that it
is mandatory.
Volunteer Signature: Date:
VOLUNTEER APPLICATION- REVISED 3/7/2023
