Thank you for your interest in becoming a volunteer at University Hospitals Ahuja Medical Center.

The first step in the placement process is completing the application below. Upon completing your application, click the "Continue" button at the bottom. Please allow up to two weeks for confirmation that you application has been received. We will contact you regarding next steps after your application is reviewed.

If you have any problems completing the on-line application or have any questions about our volunteer program, please contact the Volunteer Services Office at 216.593.5850.

We look forward to meeting you!

ATTENTION HIGH SCHOOL STUDENTS: Please do not fill out this application. There is a separate application called summer volunteer program. High school students (sophomore or higher only) may only start as a volunteer through our Summer Volunteer Program. Students who successfully meet the requirements as a summer volunteer are invited to continue volunteering throughout the school year.

Personal Data


Emergency Contact

In the event of an emergency whom should we notify?


Education


Skills and Talents

In which of these areas do you feel you have moderate to excellent skill or talent? Check all that apply.


Experience

List your most recent work experiences in the boxes labeled Employer name 1 and 2. List you most recent volunteer experiences in the boxes labeled Organization name 1 and 2.


Email

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.


Referral

Please let us know how you heard about the volunteer program at Ahuja. If a current volunteer referred you please list their name.


Background Check

University Hospitals Ahuja Medical Center does conduct background checks on those age 18 years and older. A conviction does not necessarily disqualify an applicant. Failure to disclose may result in disqualification or termination.


Consent

Health and Safety
I understand that, in participating in the UH Ahuja Medical Center (“the Hospital”) Volunteer Program, I/my child will be exposed to the normal risks of a hospital visitor or staff member.

I understand and agree that I waive for myself, my child and any heirs any and all claims including any negligence claims which I or my child might have against the hospital, or its agents or representatives, in any way arising from or relating to the Volunteer Program, except for claims arising out of the gross negligence or reckless or willful misconduct of the Hospital or its agents, or representatives. I hereby agree that I will not sue the Hospital on behalf of myself or my child, nor will my child sue on his/her own behalf, and release the Hospital from any claims I/my child, may have against it except for gross negligence or willful or reckless misconduct on the part of the Hospital, its trustees, officers, agents and employees.

In the event of exposure to blood or other bodily fluids from a patient who is a carrier of a contagious or infectious disease or a patient who is, in the judgment of the Hospital, at risk of carrying a contagious or infectious disease, the Hospital shall, with my consent, administer immediate precautionary treatment to me/my child that is consistent with current medical practice without any further consent from me.

Background Check
I authorize the Hospital to use all legal means at its disposal to assess my suitability for volunteerism including obtaining a "consumer report" (criminal background record check) about me from a "consumer reporting agency" and consider such reports when making decisions about my volunteer application. I understand and agree that the Hospital or any agent acting upon their behalf, as well as any other person responding to a reference request pursuant to this application, can and will seek and/or disclose any and all information about me which said corporation, agent, or person may have. I specifically authorize said disclosure and agree to hold such corporations, agents, or persons harmless for same. That is, I will not file a lawsuit, claim or charge against them for such disclosure. Nor will I threaten same or otherwise seek any kind of compensation for such disclosure. I further release the Hospital, its officers, partners, affiliate agents and assigns from all liability or damages caused by inquiries regarding statements made in any "consumer report" accessed by the Hospital. I also understand and agree that the criminal background check may include a fingerprinting requirement.

Submission of Application
By submitting this form, I certify that all information I have supplied in this volunteer application and any other form, oral or written, is true and accurate, and I agree that any misstated, misleading, incomplete, or false information is grounds for rejection of this application form, refusal to be accepted as a volunteer or immediate discharge from the volunteer program without recourse, whenever and however discovered.

I understand and agree that submitting this application form does not automatically register me as a volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering. By signing this form, I agree that I have read, understand, and agree to the terms of this consent form, or in the alternative, that I have read this form to my child and he/she understands and agrees to its terms. I give my full consent to my/my child’s participation in the Volunteer Program.


I Agree

I understand and agree that submitting this application form does not automatically register me as a University Hospitals Ahuja Medical Center volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.
By submitting this form, I attest that the information I have provided on the form is true and accurate.