Volunteer Application Form

URS is focused on maintaining the health and safety of the clients we serve, their families and our employees and volunteers.  We are asking that all volunteers that come indoors to interact with our clients or employees be fully vaccinated at this time.

Thank you so much for your interest in United Rehabilitation Services (URS). Please complete this application form if you are interested in becoming a URS volunteer. Once you complete the form, click the Submit button at the bottom and our Volunteer Specialist will contact you within 2 business days.

Contact Information

Demographic Information

Volunteers must be at least 14 years of age to volunteer at URS (unless accompanied by a parent or guardian).

Emergency Contact Information

In case of an emergency, who is the best person for us to contact?

Are you Volunteering to Complete Service Hours?

Are you Volunteering as Part of a Group?

Availability & Interests

Please indicate when you are available to volunteer and the type of volunteer opportunities you are interested in.

*Attention Volunteers

All volunteers at the center must have a background check at your expense (reimbursement possible) if you plan to volunteer more than 3 times. Please contact us for more information on the process for completion.

Photo Consent and Release

I Hereby give to United Rehabilitation Services of Greater Dayton (URS), its nominees, agents and assigns, my free and unlimited consent and permission, waiving all claims for any compensation by reason thereof or damages by reason therof, (1) to take photographs, moving pictures, videotapes of me and record my voice, (2) to use, publish or republish the same in the furtherance of its work with or without identification of me by name, (3) to use my name and/or information referring to me in conjunction therewith if United Rehabilitation Services so desires, and (4) in furtherance of pictures, videotapes, website and recording to and authorize any newspaper, company or other organization to use, publish, or republish the same with or without the identification of me by name and to use my name and/or information referring to me in conjunction therewith if United Rehabilitation Services so desires.

This consent agreement is in effect until otherwise notified in writing to the Executive Director of United Rehabilitation Services of Greater Dayton, by the above signed person or, if a minor, the parent or guardian signed above. Notification revoking the consent applies only to future photographs, moving pictures, website, videotapes, and recording and use of voice recording, not to those already in use.

Nut Free Zone

I understand that URS is a Nut Free Zone and I will not bring any form of tree nuts into the facility.

Volunteer/Agency Agreement & Release of Liability

This agreement is intended to emphasize the importance of our Volunteer Program and our commitment to offering you a positive and rewarding volunteer experience.

We, United Rehabilitation Services, agree to accept your services and commit to the following:

1. To provide adequate information, training, and assistance for you to be able to meet the responsibilities of your positions.

2. To ensure supervisory aid to the volunteer, and to provide feedback on their performance.

3. To respect the skills, dignity, and individual needs of the volunteer, and to do our best to adjust to these individual requirements.

4. To be receptive to any comments from the volunteer regarding ways in which we might mutually better accomplish our respective tasks.

5. To treat the volunteer as an equal partner with agency staff, jointly responsible for accomplishment of the agency’s Mission.

I, as a URS volunteer, agree to serve as a volunteer and commit to the following:

1. To perform my volunteer duties to the best of my ability.

2. To adhere to agency rules and procedures, including recordkeeping requirements and confidentiality of agency and client information.

3. To seek permission and guidance from United Rehabilitation Services staff before taking photographs of clients to ensure we are protecting the confidentiality and rights of our clients.

4. To meet time and duty commitment, or to provide adequate notice so that the staff can adjust to the change.

5. To act at all times as a member of the team responsible for accomplishing the Mission of this agency.

I, as a URS volunteer, agree to serve as a volunteer and commit to the following:

In consideration for permission to participate as a volunteer, I hereby release, waive, discharge and covenant not to sue United Rehabilitation Services (including its officers, directors, trustees, employees and volunteers) for any and all claims, liabilities, demands, costs and expenses which I may incur or claim to incur arising out of or related to services provided relative to this volunteer agreement, whether caused by the negligence of URS and its agents, or alleged as such.

I am fully aware of the risks and hazards connected with the work I have agreed to perform, including but not limited to injury resulting from slips, trips and falls, and I hereby elect to voluntarily participate with full knowledge that any such activities may be hazardous to me and/or my property. I voluntarily assume full responsibility for any risks of loss, property damage or bodily injury, including death, that may be sustained by me, whether caused by the negligence of URS and its agents, or alleged as such.

It is the express intent that this Release bind my spouse and other members of family, as well as my heirs, assigns and personal representatives.


• One of the most important aspects of HIPAA relates to the privacy of personal health information. In December 2000, the Department of Health and Human Services (HHS) issued privacy regulations (standards for Privacy of Individually Identifiable Health Information or “the HIPAA Privacy Rule”) providing standards for the protection of personal health information. This regulations purpose is to protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of the information.

• The HIPAA Privacy Rule established national standards for the protection of health information, as applied to health plans, healthcare clearinghouses, and certain healthcare providers. (Note that these are considered covered entities under both the Privacy Rule and Security Rule).

• Personal Health Information (PHI) is defined as information that is created or received by the Agency and relates to the past, present, or future physical or mental health condition of a participant, the provision of health care to a participant or the past, present, or future payment for the provision of health care to a participant, and that identifies the participant or for which there is a reasonable basis to believe the information can be used to identify the participant. PHI includes information of persons living or deceased and includes name, address, employer, relative names, birthdays, email addresses, etc.

• Penalties begin at $100 per violation, up to a maximum of $50,000. Criminal penalties apply for deliberate offences, ranging from $50,000 and one year in prison, up to $1.5 Million and ten years of imprisonment. Communications with or about patients/clients involving patient/client health information should be private and limited to those who need the information for treatment, payment and health care operations. Only those with an authorized need to know will have access to the protected information. Releasing any of this information for other than permissible purposes is a violation of the HIPAA privacy regulation. Prior to releasing any patient/client information you must have a current signed release from parent/guardian/patient

Statement of Nonconviction

Please note: All URS volunteers are required to annually sign a Statement of Nonconviction stating that you have never been convicted of or pledged guilty to crimes set forth in divisions (A)(4) or (A)(5) of section 109.572 of the Ohio Revised Code and that no child has been removed from his or her home due to abuse or neglect caused by yourself pursuant to section 2151.353 of the Revised Code. As well as a Attestation and Agreement that you have not been convicted of or plead guilt to any of the disqualifying offenses listed in Rule 5123:2-2-02 set forth by the Department of Developmental Disabilities.

At your first day of service, these documents will be required to be signed with the Volunteer Specialist.