Reinventing healthcare one patient at a time

Volunteer Application

Thank you for expressing your interest in volunteering at Ellis Medicine. Please complete and submit the application below. If you have any questions, please call the Volunteer Office at (518) 243-4009.

 

Do you have a healthcare background (If yes, please explain):

Have you been convicted of a misdemeanor or felony, and/or has pending criminal charges against you? (If yes, please explain)

Please Select Position Type


















Emergency Contact




References





Signature



AGREEMENT: I understand that by completing this Electronic Signature, that it is the equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature

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**A background check will be done on all volunteer applicants prior to being appointed to a position at Ellis Medicine**

It is the policy of Ellis Medicine to prohibit discrimination on the basis of race, color, sex, creed, marital status, national origin, mental or physical disability, age, sexual orientation or source of payment, consistent with applicable legislation and to comply with the laws pertaining thereto.