Today M-D-Y
Previous Volunteer Application and / or Service Experience at a Cleveland Clinic Location:
Yes, I have applied and served as a volunteer at a Cleveland Clinic location Yes, I have applied but not served as a volunteer at a Cleveland Clinic location No, I have not applied or served as a volunteer at a Cleveland Clinic location I am a current Cleveland Clinic Volunteer at a Cleveland Clinic location
Cleveland Clinic location: Ohio, Florida, Nevada, Toronto, London
Hon. Sister Atty. Brother Chief Dean Dr. Father (Religious) Master Mr. Mrs. Ms. Rabbi Rev. Other
Applicant Legal First Name:
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Please utilize legal name
Applicant Legal Last Name:
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Examples: Mr. Harris, Adarsh, Dr. Jones, Ms. Zhao, Bob, Lilly
CPA DDS DO Elder Esq. II III IV JD Jr. LLD MD PhD Ret. RN Sr. USAUS Army USA Ret. USAFUS Air Force USAF Ret. USMCUS Marine Corp. USMC US Marine Reserves USNUS Navy USN Ret. Other
Please share "Other" Preferred / Suffix
Today M-D-Y Click on the calendar: FIRST choose year, SECOND choose the month, LAST click on a numeric number date.
Female Male Non-binary/third gender Prefer to self-describe _________________ Prefer not to say
How do you self describe your gender:
American Indian / Alaska Native Asian Black / African American Decline to answer Multiracial / Multicultural White Other
Primary Phone:
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Cell Phone Land Line (Home) Work
Primary ______ number:
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Example: 4402166986
Preferred Phone Most Used:
Cell Phone Land Line (Home) Work Same
My preferred ______ number Is:
Example: 4402166986
I give consent for texts to come from the Cleveland Clinic Volunteer Program to my cellular device.
Yes
No
This is not to guarantee that this communication is in use currently.
Our primary mechanism of keeping volunteers informed is through email.
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Please add this email to your contact list, to avoid critical information going to your spam:
[email protected]
My Preferred Method of Contact:
Email Text Phone
How do you want us to contact you, ie., by email, text or phone
Country of Permanent Residence:
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United States of America Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo, Republic of the Congo, Democratic Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor-Leste) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon The Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Yemen Zambia Zimbabwe Other
Permanent Street Address Line One:
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Permanent Address Line Two:
Permanent City of Residence:
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Permanent State of Residence:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Maryland Massachusetts Michigan Minnesota Mississippi Missouri Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Permanent Territory of Residence:
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Other
Permanent Residence Zip Code:
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Emergency Contact First & Last Name:
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Emergency Contact Phone Number:
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Emergency Contact Relationship:
Highest grade or year of school completed:
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Under Grade 8 (No high school) Grades 9-11 (Some high school) Grade 12 or GED (High school graduate) College 1-3 years (Some college, tech school, or associate's degree) College 4 years or more (College graduate) Graduate or post-college professional degree Prefer not to answer
Cleveland Clinic volunteering requires volunteers to be at least 15 years of age.
Primary Language Spoken In My Home:
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English Algerian Arabic American Sign Language Australian Sign Language Bavarian Bengali Bhojpuri Burmese British Sign Language Czech Dutch Eastern Punjabi Egyptian Arabic French Gan Chinese German Greek Gujarati Hakka Chinese Hausa Hejazi Arabic Hindi Igbo Indonesian Iranian Persian Italian Japanese Javanese Jin Chinese Kannada Korean Maithiki Malayalam Mandarin Chinese Marathi Min Nan chinese Morroccan Arabic Northern Uzbek Odia Polish Portugese Romanian Russion Sa'idi Arabic Sindhi Spanish Sudanese Arabic Sundra Swedish Tagalog Tamil Telugu Thai Turkish Ukrainian Urdu Vietnamese Western Punjabi Wu Chinese Xiang Chinese Yoruba Yue Chinese Zulu Other
Second Language Spoken in my Home:
Algerian Arabic American Sign Language Australian Sign Language Bavarian Bengali Bhojpuri Burmese British Sign Language Czech Dutch Eastern Punjabi Egyptian Arabic English French Gan Chinese German Greek Gujarati Hakka Chinese Hausa Hejazi Arabic Hindi Igbo Indonesian Iranian Persian Italian Japanese Javanese Jin Chinese Kannada Korean Maithiki Malayalam Mandarin Chinese Marathi Min Nan chinese Morroccan Arabic Northern Uzbek Odia Polish Portugese Romanian Russion Sa'idi Arabic Sindhi Spanish Sudanese Arabic Sundra Swedish Tagalog Tamil Telugu Thai Turkish Ukrainian Urdu Vietnamese Western Punjabi Wu Chinese Xiang Chinese Yoruba Yue Chinese Zulu Other
Architecture and Engineering Arts, Design, Entertainment, Sports, and Media Building, Grounds Cleaning, and Maintenance Business and Financial Operations Computer and Mathematical Construction and Extraction Education Instruction and Library Farming, Fishing, Forestry Food Preparation and Serving Healthcare Practitioners and Technical Healthcare Support Inside the Home Installation, Maintenance, and Repair Legal Life, Physical and Social Sciences Office and Administrative Support Personal Care and Service Production Protective Services Sales Transportation and Material Moving Other
If you are retired, please also check your primary occupation prior to retirement.
How might you describe your role with ______ ?
Examples include but are not limited to: Civil Engineer, Doctor, University Professor, Chief Executive Officer, Respiratory Therapist, Nurse, Stylist, Real Estate Agent
Please describe "Other" occupation category:
I am a current or former employee of Cleveland Clinic:
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Yes
No
Previous employment does NOT prevent you from volunteering.
Area of employment at Cleveland Clinic (Location, Unit / Department, Role):
Example: Hillcrest, Emergency Dept., Nurse, or Medina Hospital Trustee
I am related to a current Cleveland Clinic Caregiver, Board Member, or Trustee of Cleveland Clinic:
* must provide value
Yes
No
Relative role, work/service location, name:
Example: Nurse, Hillcrest Hospital, Jane Doe
Did someone refer you to Volunteer Services?
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Yes
No
Please share the name of the person(s) or event that referred you to Cleveland Clinic Volunteer Services and the circumstances:
Example: Dr. Majikas referred me during my visit with her.
I discovered Volunteer Services in this way:
Check all that apply
Volunteer Service Interest:
* must provide value
Check all that apply
I would consider learning about and then deciding whether I would like to participate in changing the delivery of healthcare and enhancing the Cleveland Clinic patient and caregiver experience if one of the opportunities became available as a one opportunity or short term project:
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THANK YOU for your interest in Healthcare Partner service for Children's Hospital.
This program seeks to engage the voices of those families who have been PATIENTS (or parents of patients) of Children's Hospital.
I am the parent or legal guardian of ______ ______ and I grant permission for him / her to apply to a Cleveland Clinic Volunteer Services program.
Signature is required for minors.
Please print the name of the parent or legal guardian that granted permission for this application by signing above.
Required for all minors.
Describe "Other" Volunteer Opportunity of Interest:
______ 's approximate Date of Birth:
Today D-M-Y
Canine needs to be greater than one year of age in order to volunteer at Cleveland Clinic.
How long have you had ______ :
Please enter number of years
What breed of dog is ______ :
Is your Dog Certified as a Therapy Dog?
Yes
No
Caring Canine Volunteers are required to be certified as a Therapy Dog. If your dog is not certified, we can share information about certifying organization.
Any Additional Information about ______ that may be important:
The Healthcare Partner program is interested in your input and input from other patients, families or support persons, how would you like to provide input? For example: (read list below):
Please check all that apply
If sharing your point of view is part of your role, the focus will be on:
Please check all that apply
What excites you about being a Cleveland Clinic Volunteer?
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What is one thing you would like to see Cleveland Clinic do differently?
Commitment Overview and Confidentiality AgreementCleveland Clinic Volunteers are patients, family members and/or support persons who work together with Cleveland Clinic Caregivers to transform healthcare and support our vision of Patients First and providing relationship-centered care. Patients, support persons and caregivers as partners for better health Improving Healthcare through collaboration Volunteers serve in many different ways to improve healthcare through collaborative efforts with leadership, caregivers, healthcare partners and the community. The Cleveland Clinic appreciates the critical role you will play in transforming healthcare. Participation may occur throughout the Cleveland Clinic including main campus, regional hospitals, outpatient family health centers and primary care practices. As a Volunteer, you will be invited to share your perspective on the Cleveland Clinic, its culture, approaches to and delivery of care and the patient experience. Often this will occur in a group setting with other participants present; and therefore, some confidentiality may be lost by revealing information in a group setting. We ask that you respect one another's' confidentiality and not discuss names or other identifying information of patients, families, and support persons connected with the program or the Cleveland Clinic. Similarly, the Cleveland Clinic will not share any individually identifiable information obtained as a result of participating in the Our Voice: Healthcare Partner program. More specifically: • Confidential information may be discussed between Volunteers and Cleveland Clinic Caregivers. Such confidential communications must be kept confidential and within participants of this program. • You may not communicate confidential information outside of the Volunteer scope of service or direct others to undertake aspects of the work. • You must respect the private and sensitive nature of this program. • All information shared during or related to this program shall be used only within the context of this program. Participants selected to be Cleveland Clinic Volunteers are asked to commit to one year of service. An option to rejoin for one additional year may be discussed at the conclusion of the first year of service. Cleveland Clinic may remove a participant from the program at its discretion. There will be no compensation for participation. Participants selected will complete an on-line on boarding process, attend an orientation session and receive information regarding the specific schedule required for their assignment prior to their start. By signing below and participating in the Cleveland Clinic Volunteer Program, you understand that you are choosing to abide by the guidelines described above. While the Cleveland Clinic respects and abides by its regulatory obligations regarding privacy and ensures all reasonable measures are taken to protect information, it may not be able to completely safeguard the privacy and confidentiality of what you choose to discuss or responses offered. Therefore, you agree that the Cleveland Clinic shall not be liable for any financial or other damages resulting from the shared nature of this program and/or other participants in the program. In accordance to the Cleveland Clinic's commitment to maintaining the privacy of its patients, you also agree to protect the privacy of other CC Volunteers by not identifying other participants or discussing their personal information and/or medical condition outside of the Volunteer Program. By signing below, I acknowledge that I have read and agree to abide by the requirements stated above. (Click Add Signature and use your mouse to sign your name in the box below)
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I would consider attending meetings virtually (from a distance by computer) using the following ways to connect:
Training and connection information would be provided to you. There would be no cost for computer / mobile device download.
I am most interested in volunteering at:
* must provide value
Describe "Other" area of volunteering:
I am most interested in volunteering at this hospital:
* must provide value
Akron General Medical Center Ashtabula County Medical Center Avon Hospital Cleveland Clinic Children's Cleveland Clinic Children's Hospital for Rehabilitation Cleveland Clinic Main Campus Cleveland Clinic Weston Florida Euclid Hospital Fairview Hospital Hillcrest Hospital Indian River Justin T Rogers Care Center / Hospice Care Lodi Hospital Lutheran Hospital Cleveland Clinic Martin North Hospital Cleveland Clinic Martin South Hospital Cleveland Clinic Martin Tradition Hospital Marymount Hospital Medina Hospital Mentor Hospital Mercy Health South Pointe Hospital Union Hospital Weston Hospital Other
I am most interested in volunteering at this Family Health Center / Medical Office / Outpatient Setting:
* must provide value
Amherst Family Health Center Avon Family Health Center (Richard E. Jacobs) Bath HWC Beachwood Family Health Center Behavioral Health Center Vero Beach, Florida Brunswick Family Health Center Cancer Center Mansfield, OH Cancer Center Sandusky CC Children's Rehabilitation Therapy Services- BEACHWOOD CC Children's Rehabilitation Therapy Services- MEDINA CC Children's Rehabilitation Therapy Services- MIDDLEBURG HTS. CC Children's Rehabilitation Therapy Services- STOW / FALLS CC Children's Rehabilitation Therapy Services- WESTLAKE CC Family Health Center Stuart, Florida CC Main Campus Internal Medicine Chagrin Falls Family Health Center Coral Springs Medical Center Egil and Pauline Braathen Medical Center Weston, Florida Elyria Family Health Center Fairview Medical Office Building Green HWC Health and Wellness Center Vero Beach, Florida Independence Family Health Center Indian River Krupa Center Weston, Florida Lakewood Family Health Center Lodi Community Care Center Lorain Family Health Center Lou Ruvo Center for Brain Health - Las Vegas, Nevada Martin Health at Hobe Sound Martin Health at Palm City Martin Health at St. Lucie West Martin Health at Tiffany Martin Health at Tradition Park One Martin Health at Tradition Park Two Martin Health, Robert and Carol Weissman Cancer Center Marymount Medical Office Building Medina Medical Office Building Mentor Medical Office Building Moll Cancer Center at Fairview Hospital North Olmsted Medical Office Building Palm Beach Gardens Parkland: Parkland, Florida Scully-Welsh Cancer Center Vero Beach, Florida Sheffield Family Health Center Solon Family Health Center South Pointe Medical Office Building Stephanie Tubbs Jones Health Center Stow HWC Strongsville Family Health Center Tomsich Health and Medical Center of Palm Beach County West Palm Beach, Florida Twinsburg Family Health Center Weston Family Health Center Willoughby Hills Family Health Center Wooster Family Health Center None Other
Alert: Akron General Volunteer Services Department completes Background checks, inclusive of fingerprinting, for all volunteers.
I am most interested in volunteering with:
* must provide value
Check all that apply
Opportunities to volunteer with Infants and Children patients are not available at the following locations at this time: Cleveland Clinic Family Health Centers & Medical Office Buildings Hospice Ashtabula County Medical Center Avita Health System Bucyrus Hospital Avita Health System Galion Hospital Avon Hospital Cleveland Clinic Abu Dhabi Cleveland Clinic London Cleveland Clinic Weston Florida Euclid Hospital Hospice Care Indian River Justin T Rogers Care Center / Hospice Care Lodi Hospital Lutheran Hospital Lou Ruvo Center for Brain Health Martin North Hospital Martin South Hospital Martin Tradition Hospital Marymount Hospital Medina Hospital South Pointe Hospital Union Hospital Weston Hospital
I have previous and / or current volunteer experience.
* must provide value
Yes
No
I have had previous Hospice experience.
Yes
No
Please share more about your Hospice experience:
Dates of Service with Hospice
Role with Hospice
Relationship with Hospice
Location(s) Served
Any Additional Information
Share as applicable
Please share your previous volunteer experience information:Location of Service
Dates Served
Approximate Hours contributed
Reason for discontinuing service (if applicable )
Please download, read, and save a copy of Cleveland Clinic Volunteer Handbook
I did download the Volunteer Handbook using the link above.
Yes
No
I acknowledge receipt of the Cleveland Clinic Volunteer Handbook. I acknowledge that I have read and understand the content of the Cleveland Clinic Volunteer Handbook and accept full responsibility for familiarizing myself with the policies contained within, I understand that the information contained in the Volunteer Handbook may be updated periodically and that I can obtain updated policies and information by contacting my Cleveland Clinic Volunteer Coordinator or Volunteer Services at 216.445.6986. I recognize that the Volunteer Handbook, as well as any written or oral communication made at the time of commencement of volunteer work, or subsequently, is not intended in any way to create a contract between Cleveland Clinic and myself. I understand that volunteerism does not create an employment relationship and the volunteer relationship is entered into voluntarily and many be terminated by Cleveland Clinic or me at any time regardless of circumstance. I understand that Volunteer Services at Cleveland Clinic may involve service that may create hazards to me, including but not limited to lifting and carrying heavy items. I understand that it is my responsibility not to engage in tasks that are beyond my physical limitations and abilities and will notify CC Volunteer Services Coordinator or Volunteer Services at 216.445.6986 if I believe this is ever the case. I understand that, for safety purposes, Cleveland Clinic completes background checks on volunteers. If I have any questions about the content, interpretation or application of the Volunteer Handbook to me, I agree to immediately bring any questions to the attention of a Volunteer Coordinator. I understand that the information, observations, and knowledge gained through my participation as a Cleveland Clinic Volunteer must not be used for personal, professional, or business gain inside or outside of the Cleveland Clinic. I attest to that I read, understood, and agree to abide by the content of the modules that are listed below. If I have any questions regarding understanding and execution of the content of these modules, I will contact Cleveland Clinic Volunteer Services Department at 216.445.6986 for further instruction. I understand that review of additional materials may be required in the future, and if that is the case, I will be notified.
i. Corporate Compliance: Prevention, Detection, and Reporting ii. HIPAA Overview iii. Information Security Awareness iv. Stroke: Overview for Caregivers v. Diversity and Inclusion vi. SERS for all Caregivers vii. Patient Safety Please add signature below:
Next Steps
A Volunteer Coordinator will be in touch with you within 5 - 10 business days of this application to assist with these next steps.
Acceptance into the Cleveland Clinic Volunteer Program, is not automatic. In addition to this application, placement will be determined by: Interview, Availability of Opportunities, and successful progression through TB testing & designated Cleveland Clinic Non-Employee onboarding software.
1) Applicant Interview
2) Applicant designated Cleveland Clinic Non-Employee Onboarding software program
completion, including background check conducted by Cleveland Clinic.
3) TB testing
4) Fingerprinting (additionally required if volunteering with / near children, & as needed if
volunteering with vulnerable populations)
5) Watch Cleveland Clinic Orientation
6) Site Specific Orientation
7) Obtain badge
8) Parking (as applicable)
I am a United States citizen:
* must provide value
Yes
No
Please share your VISA type, for further consideration.
Individuals who are not U.S. citizens, but who reside in the U.S., may volunteer
(1) if they are a lawful permanent residents; or
2) if they are non-immigrant aliens with F-1 or J-1 visa status, who are bona fide students residing in the U.S. solely to pursue a course of study at a recognized, approved institution of education.
Foreign students may volunteer with a Federal natural resource agency if they have successully received permission to engage in Optional Practical Training (OPT), Curricular Practical Training (CPT) or Academic Training (AT).
For more information and instructions, students should consult the international student advisor at their university. An offer of employement or verification of a volunteer placement must be submitted with the student's application for OPT, CPT or AT. F-1 student visa holders may be required to submit applications for off-campus training and work to the international student advisor and United States Citizen and Immigration Services (USCIS) several months in advance of the proposed start date of the program. J-1 student visa holders may participate in academic training with the approval of their academic advisor and the J-1 responsible officer at their sponsor organization or institution.
Source :https://www.volunteer.gov/faq.cfm
Enter Visa Type Here
Thank you for your interest in Cleveland Clinic Volunteer Program. Please share anything more that you would like us to know, below:
I acknowledge the following: I acknowledge the answers given here are true and complete. I realize that my potential volunteer service in no way commits Cleveland Clinic to future employment.
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