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UI Health Care Community Volunteer Preregistration Application

Thank you for your interest in volunteering at University of Iowa Hospitals & Clinics and UI Stead Family Children's Hospital!

Please submit this form to preregister as a UI Health Care Volunteer. If you experience any difficulty while filling out this form, please contact volunteerservices-vsys@uiowa.edu.

Once our staff has reviewed your form, we will be in touch with more information within 5 business days.

We look forward to helping you make a difference!

All fields marked with * are required.

General Information
Volunteer Experience
Education
Please list your education history*
Employment History
Please list your employment history dating back five years*
References
Provide three references (professional references preferred; no relatives or personal physicians)*
NOTE: Three references are required. Applications submitted with fewer than three references will be rejected.
Health and Emergency Information
Background Information
University of Iowa Health Care must be able to assure the safety of all patients in their care. Therefore, we ask you to provide us with the following information which will remain in the strictest confidence, which means that we shall use our best efforts to ensure that the following information will not be released other than to comply with a court order, subpoena, or as otherwise required by law. Otherwise such information will only be used to determine your suitability for placement. The existence of a criminal conviction history is considered only to the extent that it relates to a particular volunteer position.
Note: In addition to answering these three questions, all volunteers must pass a full criminal background check before they can begin volunteering.
Short Essay
Volunteer Commitment Agreement

I understand that to become a UI Health Care volunteer, I am required to make a commitment to volunteering three hours per week for a period of six consecutive months following my placement in a unit. This equates to over 72 total hours. Considerable hospital resources are dedicated to screen, collect background information, health screen, photo ID badge, and appropriately orient, assess, train, place, and supervise volunteers at the hospital, all of which are provided at no cost to me. In addition, the dependability of volunteers directly affects the quality of the placements available to me, particularly in areas with direct patient contact.

With this in mind, I have considered my obligations, and should I be accepted as a UI Health Care volunteer, I pledge to contribute three hours per week for a minimum of 72 total hours.

Declaration and Application Signature
As a UI Health Care volunteer, I understand that Volunteer Services reserves the right to terminate any volunteer status as a result of (a) failure to comply with hospital policies, rules, and regulations; (b) absences without prior notifications; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgement of the Volunteer Services Director, would make my continued services as a volunteer contrary to the best interests of the hospital. In addition:
Nondiscrimination Notice
The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, creed, color, religion, national origin, age, sex, pregnancy, disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity, associational preferences, or any other classification that deprives the person of consideration as an individual. The university also affirms its commitment to providing equal opportunities and equal access to university facilities.
For additional information on nondiscrimination policies, contact the Director, Office of Equal Opportunity and Diversity, the University of Iowa, 202 Jessup Hall, Iowa City, IA 52242-1316, 1-319-335-0705 (voice),1-319-335-0697 (TDD), diversity@uiowa.edu.