Volunteer Application

Do you currently hold a license to sell health or life insurance in NY?

Yes No

Medicare Rights Center regrets that, for reasons of conflicts of interest, we cannot accept volunteers who are licensed to sell health and/or life insurance.

Volunteer Information

If possible, please upload your resume.

How did you hear about Medicare Rights Center?

Education & Training

Educational Background

Please list below your educational background including high school, college, trade and any military service.

Other Vocational and/or Professional Information

Please list any other professional information (i.e., research projects, thesis subject, publications, patents, seminars, hobbies, or volunteer work) you believe is relevant to the volunteer position.

Are you currently employed?

Yes No

Volunteer Motivations

Why do you want to volunteer with the Medicare Rights Center? What do you hope to gain from this experience?

Please describe any special training or skills you have that may help you in your volunteer position at the Medicare Rights Center.

Volunteer Role

If you are interested in the Helpline volunteer position you will be required to attend a 1 day in-person training session.

Do you speak any language other than English?

Yes No

If yes, which languages?

Please describe your level of experience with computers (e.g., Proficient in Microsoft Word, comfortable using online search engines such as Google).

Approximately how many hours per week do you wish to volunteer (minimum 4 hours)?

Which day(s) of the week do you prefer to volunteer? (Helpline shifts are from 10-3, M-F)

Relevant Work and Volunteer Experience

Please describe any relevant volunteer or work experience. Whenever possible, please include organization names and dates of service.

Dates of Employement

References

Please provide two references (e.g., non-family members).

Company/Organization

As part of the application process, you will have a follow-up phone interview with a Medicare Rights staff member. When are you most readily available?

Morning Afternoon

Have you ever been convicted of any criminal offense by a civilian court or by military authorities (excluding traffic violations)?

Yes No

If yes, are you currently on probation or parole?

Yes No

I understand that this is an application for, and not a commitment or promise of, a volunteer position at the Medicare Rights Center. I understand that prior to volunteering I may be required to complete a training program.

I certify that I have provided, and will continue to provide, information throughout the selection process that is true to the best of my knowledge (including information provided on this application and in conversations with the Medicare Rights Center). I understand that information contained on my application may be verified by Medicare Rights Center.

Volunteer Information

Education & Training

Volunteer Motivations

Volunteer Role

Relevant Work and Volunteer Experience

References

Disclaimers

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