Personal Information
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Emergency Contact
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Educational Information
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Demographics (Optional)
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Background Checks
A record of criminal conviction will not necessarily be a bar to volunteering, since the Hospital will consider factors such as age at time of offense, how long ago the conviction occurred, the nature and seriousness of the violation and evidence of rehabilitation in making a volunteer decision. Since Children?s is a pediatric hospital, certain criminal offenses are by Ohio law automatic disqualifiers for volunteer assignments no matter when they occurred.
Click if yes
Click if yes
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HIPAA/Confidentiality/Security Training

In order to comply with HIPAA (Health Insurance Portability and Accountability Act), other privacy laws, and other health care accreditation guidelines as well as professional ethics standards, it is imperative that all Project Volunteers understand, respect and follow the Akron Children's Hospital confidentiality policy. We ask that you read this "Confidentiality Statement" carefully. We will keep your signed copy on file. Please ask an Akron Children's Hospital employee if you have any questions or concerns regarding this confidentiality requirement.

I understand that by virtue of my presence at Akron Children's Hospital, I may be informed of certain health information that is necessary to accomplish the goals of my visit or may inadvertently receive such information.  To ensure HIPAA and other privacy laws are not violated, I understand Akron Children's Hospital's policy not to share any health information about another person.

By signing below, I acknowledge that I will keep confidential all health information that I become aware of during my visit.  This includes information about any health condition, testing, treatment, surgery, medications, or procedures related to the health of an individual.  In addition, I agree not to use or to disclose this information to any person.

I understand that as a Project Volunteer I am responsible for maintaining the confidentiality of all information related to Akron Children's Hospital. This Agreement prohibits the unauthorized verbal, written or electronic communication of any information about patients, families, physicians, employees, donors, and volunteers which is of a medical, personal, or financial nature, including the fact a patient was admitted to the Hospital or to any other Akron Children's Hospital facility.

I also understand and agree, as part of being a Project Volunteer, that what I see, hear or read in any Akron Children's Hospital facility pertaining to the above may only be discussed on the premises with members of staff for purposes which benefit the organization's stated objectives.

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Hospital Instructions
Akron Children's Hospital (ACH) and its subsidiary organizations are dedicated to providing a healthy work environment for all who enter our campus. The goal is for all individuals providing services on behalf of ACH to embrace the Mission of the Hospital.
MISSION

Service to the Community intended to improve the health status through lay education.

Patient care for infants, children, adolescents and burn victims of all ages.

Education for students of medicine, nursing, and the various allied health professions.

Advocacy for child and family to improve the status of children and adolescents.

Research into the causes, treatment and cure of childhood illness/injury and burn injury.

EMERGENCY CODES
Emergency situations are announced by color via overhead page. The phone number to report any emergency situation is "22." If an emergency code is announced, you are to follow the direction of Children's employees.

PATIENT RIGHTS
All patients have the right to have personal and medical information kept confidential.  Discussing any hospital or patient information with anyone who does not have a bona fide need to know is prohibited.  Your assigned department will educate you regarding any privacy issues that relate to the Health Insurance Portability and Accountability Act (HIPAA) which are federal regulations that safeguard protected health information.

INFECTION CONTROL
Infections are easily spread by hands. Follow the hand hygiene policy by either washing with soap and water or using an alcohol-based hand sanitizer (such as Purell) before and after every patient contact. Follow the Body Substance Precautions Policy by wearing protective equipment such as gowns, gloves and masks.
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Statement of Committment

I hereby affirm that the information provided on this application is true and complete.  I understand that any false or misleading representations or omissions may disqualify me from further consideration for Project Volunteer opportunities and may result in discharge even if discovered at a later date.  I understand as a Project Volunteer I am responsible for maintaining the confidentiality of patient and family members.

I also agree to the terms and conditions of the HIPAA/Confidentiality/Security training and the hospital instructions which were reviewed with me by a Volunteer Services staff member. I authorize Akron Children's Hospital to verify any information I have provided. I hereby authorize persons from any schools, companies, or organizations, to include my references, named in this application to provide information about me contained in their records, and I release all such persons from liability regarding the provision of or use of such information.

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Parental Consent
has my permission to be a Project Volunteer at Akron Children's Hospital.
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Authorization to Consent to Treatment of Minor
a minor, do hereby authorize Akron Children's Hospital to consent to any diagnostic, medical, surgical treatment of hospital care which is determined necessary by a licensed physician on the medical staff of Akron Children's Hospital. This authorization is valid when such diagnostics, treatment or care is considered by the physician or surgeon to be reasonably necessary to preserve the life of, or prevent serious impairment to, the health of the teen project volunteer and the minor's parent/legal guardian is not immediately available to consent to such treatment.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required to provide specific consent to act in situations described above until such time as a parent or legal guardian is available to act on behalf of the teen.

 This authorization will remain in effect until the minor's eighteenth birthday, unless revoked in writing and presented to the Volunteer Services Department of Akron Children's Hospital.

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