Please complete this application form if you are interested in becoming a member of the University Hospitals Samaritan Medical Center Auxiliary. Once you complete the form, click the Continue button at the bottom.

NAME, ADDRESS, PHONE, EMAIL:


I want to join the Auxiliary because:


Relevant Skills and Experience:


Current or Most Recent Employment:


Education and Training:


References:


I Agree

I understand and agree that submitting this application form does not automatically register me as a University Hospitals Samaritan Medical Center Auxiliary member, and that there may be certain qualifications I must meet, including the acceptance of established Auxiliary 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.