Patient and Family Advisor Application

We will be conducting a criminal background check, fingerprinting, TB screening and a drug screening. Please note that all volunteers must be vaccinated for COVID-19 and must receive a flu vaccine yearly.

New User Details

User ID

User ID (verify)

Password

Password (verify)

You must be 18 years of age or older to volunteer. Please fill out the application below.

Personal Information

Title

First name *

Middle name

Last name *

* Street Address Line 1

Line 2

City *

State *

Zip/postal *

Phone *

E-mail *

Do you allow your contact information to be shared with other committee/advisory board council members?

I am a

Volunteer Interest

Why are you interested in volunteering with The MetroHealth System?

Days of the week available to volunteer *

Time of day available to volunteer

Have you ever worked or volunteered for The MetroHealth System? *

If yes, indicate the facility, your position, and dates of service:

* Why do you want to be a Patient and Family Advisor?

How did you hear about becoming a Patient and Family Advisor?

Do you have any committee or related project experience you would like to share?

Do you have an interest in any of the following?

References

Please list two persons we may contact for a personal reference. Do not list relatives.

Name

Phone

Address 1

City

State

Zip/postal

Name

Phone

Address 1

City

State

Zip/postal

Employment/Education/Volunteer Experience

Employment Status & School Info

Employment Status

Employer

Position

Start Date

I am a student.

School

Volunteer Experience

Describe your present/past volunteer experience, including name of organization, type of assignment, and dates:

Miscellaneous

1) Are you receiving an Ohio Public Employees Retirement System (OPERS) disability benefit? *

2) Are you applying to fulfill a school, graduation or government program requirement for service? Please specify how many hours you need and any other special requirements. *

Please Explain if you selected YES:

Person to be contacted in case of emergency

Contact name

Relationship

Phone

Acknowledgement and Signature

I certify that all the information on this form is true and accurate, I understand that all application information will be verified and that false statements or omissions will be considered grounds for immediate dismissal, no matter when such information is discovered or reported to The MetroHealth System. I understand that if I volunteer, I must become familiar with and abide by all the policies of The MetroHealth System. I further understand that my volunteering is conditional upon satisfactory completions of reference and background checks, as well as drug screening. Certain conditions would not apply if the volunteer is a minor.

By submitting this form, I attest that the information I have provided is true and accurate.

[ clear ]

Signature of Applicant. Please use your mouse or finger to sign.

Existing Volunteers