PFAC Application

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To minimize potential conflicts of interest, individuals who are currently employed in a clinical role at another hospital are not eligible for PFAC membership.

Contact and Demographic Information

Legal Name

* First

Middle name

* Last

First name (preferred)

Preferred Pronouns (optional)

Age

Please note: YOU MUST BE A MINIMUM OF 16 YEARS OF AGE TO APPLY.

Do you have a US Social Security Number?

Please note a US Social Security number is required for applicants 18 and over.

Address

* Address/ House Number + Street

Apt. #

* City/Town

State

* Zip

Phone (Cell/Mobile)

Phone (Home)

Preferred phone type

* Email

Personal Information

Please select your race/ethnicity (voluntary)

Sex

For which Council are you applying? (select only one)

Department(s)/Division(s) where you/patient have been seen (can select more than one):

Adolescent Medicine

Allergy and Immunology

Audiology

Bone Marrow Transplant (BMT)

Cardiology

Cardiac Intensive Care (CICU)

Child Life

Dentistry

Dermatology

Emergency Department (ED)

Endocrinology

Gastroenterology

Genetics

Gynecology

Hematology

Infusion Therapy

Neonatal Intensive Care Unit (NICU)

Neurology and Neurosurgery

Nutrition

Occupational Therapy/Physical therapy (OT/PT)

Ophthalmology

Oncology

Orthopedics

Otolaryngology/Ear Nose and Throat (ENT)

Pain Management

Pathology

Plastic Surgery

Pulmonary Medicine

Palliative Care

Pediatric Intensive Care Unit (PICU)

Physical Medicine and Rehabilitation

Primary Care/General Medicine

Psychiatry

Radiology

Respiratory Therapy

Rheumatology

Social Work

Speech-Language

Sports Medicine

Surgery

Transplant Medicine

Urology

Other

Emergency contact

In case of emergency, whom should we contact?

* Name

* Phone (Preferred))

* Relationship

General Information

Please indicate your experience with NYP

If you are a family member or care partner, please tell us the name of the patient you are representing

Patient name

Check here if patient is a minor

Patient phone

Patient relationship

Please briefly describe your or your family member's experience at New York-Presbyterian

* Have you previously volunteered at New York-Presbyterian? In what capacity?

* How did you hear about the Patient Family Advisory Council?

At NYP our initiatives support our ultimate goal: We Put Patients First. This means that in everything we do, we must make patients our first priority and strive to provide them with the highest quality, safest, and most compassionate care and service.

* How can you help us further this initiative as a volunteer?

* What would you hope to gain from your experience at NYP?

Employment or Volunteer Experience Information

NYP Employee

* Campus/department

* Date of separation

Please list most current experience first.

Employer/Volunteer Organization #1

Company or Organization Name

From

To

Reason for Leaving

Title, tasks and/or duties

Name and title of Supervisor

Telephone

May we contact supervisor?

Employer/Volunteer Organization #2

Company or Organization Name

From

To

Reason for Leaving

Title, tasks and/or duties

Name and title of Supervisor

Telephone

May we contact supervisor?

Volunteer Character Reference

I authorize NewYork-Presbyterian Hospital, or any agent it expressly authorizes to act on its behalf, to investigate fully all the information and references contained on my application for a volunteer opportunity. I release my current employer as well as former employees and other appropriate references from any liability and responsibility for providing written or verbal information about me to NewYork-Presbyterian Hospital.

APPLICATIONS MUST INCLUDE A COMPLETED VOLUNTEER CHARACTER REFERENCE IN ORDER TO BE REVIEWED.
Family members should not act as a reference.

* Reference - Name

* Phone

* E-mail

Hospital Recommendation

I authorize NewYork-Presbyterian Hospital, or any agent it expressly authorizes to act on its behalf, to investigate fully all the information and references contained on my application for a volunteer opportunity. I release my current employer as well as former employees and other appropriate references from any liability and responsibility for providing written or verbal information about me to NewYork-Presbyterian Hospital.

* Staff member name

* Hospital department

* Email

* Phone

Personal Statement

Please read the following statements carefully, as they represent matters of importance to you and to NewYork-Presbyterian Hospital in connection with this volunteer application. After you have read the form in its entirety, please sign below.

I understand and agree that:

The information provided in this application, in my resume (if supplied) and during my interview(s) is true and complete to the best of my knowledge. I understand that any false or misleading statements on this application, on my resume, on any prescreening documents or in my interview(s) will justify refusal of volunteer status or, if I am hereafter on boarded by NewYork- Presbyterian Hospital, termination of my volunteer status
NewYork-Presbyterian Hospital may verify all the information that I have provided on this application, and I release NewYork- Presbyterian Hospital and its representatives from liability for seeking such information and I release from all liability whatsoever all persons, institutions, business entities, and corporations providing NewYork-Presbyterian Hospital with such information. I further agree to sign whatever consent forms may be necessary to permit NewYork- Presbyterian Hospital to verify all the information that I have provided in this application.
I understand that in accordance with New York State law, if I am offered a volunteer opportunity, I agree to undergo background screening, if applicable, and that such offer and continued volunteering are conditional upon satisfactory clearance by the Hospital's Workforce Health & Safety Department, which includes drug testing, and satisfactory reference verification and other general information provided on this volunteer application.
I understand that if I am offered a volunteer opportunity, my volunteering will be "at will," meaning that either I or NewYork-Presbyterian Hospital may end the volunteer relationship for any lawful reason, at any time, with or without notice.

In consideration of any volunteer opportunity which may be offered to me, I agree to comply with policies, rules, regulations, and procedures of NewYork-Presbyterian Hospital.

My name typed below will stand as my signature, confirming the completeness and accuracy of the information I provided above, and will carry the same force and effect as if it were signed and affixed by my hand.

* Typed name

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Signature