UH EMC Student Volunteer Application

Dear Future Student Volunteer,

Thank you for your interest in becoming a student volunteer with University Hospitals Elyria Medical Center. Volunteers are a valued extension of the medical staff and serve a vital role in making a meaningful difference in the lives of others. It also offers an opportunity to interact with medical professionals, learn new skills, and earn school credit for volunteer service.

Our student volunteers are held to a high standard of commitment and professional behavior. You will represent all of us. If you do not yet qualify, please check back in the future. If you do qualify, let’s get started!

REQUIREMENTS

1. Minimum age of 15 years and/or in the ninth grade.

2. Grades in academic subjects must be "B" or better.

3. Maturity level to work independently and with professionalism.

4. Willing to commit to one shift per week during their selected session.

5. Attend an orientation.

6. Proof of negative TB test given within the past 12 months

7. Proof of flu vaccination during designated months

8. Ability to effectively communicate orally and in writing in English

GENERAL INFORMATION: Student volunteers are asked to commit to a minimum of one shift per weekday (4-6:30pm) during one of four sessions. More than one session can be selected.

(1) Fall: Aug-Oct (2) Winter: Nov-Feb (3) Spring: March – May (4) Summer: June-Aug.

It is important to select the session that will allow you to volunteer consistently on a weekly basis and to not miss 3 or more weeks. Missing 3 or more weeks could result in your volunteer position being given to another volunteer.

1. Student volunteers deliver flowers, admit/discharge patients and assist hospital personnel. On occasion, they are asked to assist with mailings and other office tasks. They may be assigned to other areas in the hospital based on maturity, dependability, need and career interests. Students volunteer Monday through Friday from 4:00 – 6:30 p.m. During the summer, student volunteer opportunities are available during daytime business hours as well.

2. Students working in the Gift Shop run the cash register, accept payments, unpack gift items, restock shelves, and assist with maintaining the appearance of the shop.

INSTRUCTIONS: Students must sign and complete the application and secure parent/guardian's signature on the Application, Dress Code Agreement, and Confidentiality Statement. A school counselor should complete the "Counselor Evaluation."

When all forms have been received in Volunteer Services, you will be called regarding your availability and an appointment will be set for an orientation. If you have any questions, please call 329-7362 or email Lois.Koehler@UHHospitals.org

General Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

Street 3:

City:

Ohio:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

* OK to call me here

Email address:

Prior volunteer experience:

About You:

Help us get to know you better by telling us why you are interested in volunteering. Together we can identify the volunteer opportunity that will best utilizes your skills and abilities. Please note that several roles have age and skill minimums.

Date of birth:

Education:

Currently attending High School:

Currently attending College:

Year of Graduation:

Location

Please indicate the location where you are interesting in volunteering. Volunteer opportunities vary depending on location.

UH Elyria Medical Center:

UH Amherst Medical Center

UH Avon Health Campus

UH Elyria Medical Center

Are any family members currently employed by UH?

If so, what facility and department?

Availability

References

Please provide the names of three (3) ADULT references (excluding relatives, doctors, or teachers) that can be contacted Monday-Friday between 8:00am and 4:00pm.

1

2

First name:

Last name:

Home phone:

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

Relationship:

3

First name:

Last name:

Home phone:

Work phone:

OK to call here

Cell phone:

Relationship:

Skills and Interests

Emergency Contacts

Should an emergency happen while you are volunteering, who should be contacted?

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Criminal History

Volunteers are required to have a Federal and State background screening. Prior to your screening, please answer the following questions: Have you ever been convicted of a

Minor Healthcare Misdemeanor.:

Felony:

Parent/Guardian's Consent For Minors

Once your application has been submitted, a parental consent, dress code policy, and school counselor's evaluation will be sent through email to be signed and returned to Volunteer Services.

Afformation of correct information:

By signing this application, I swear and affirm that I have never been convicted of a criminal offense other than a minor traffic offense. I understand that any misleading or any incorrect statements may render this application void and would be cause for immediate dismissal in the event of placement and expressly release the hospital from any and all claims which might arise out of service as a volunteer.

I Agree