United Rehabilitation Services of Greater Dayton

Contact information

First name First name

Enter a first name

Last name Last name

Enter a last name

Phone Phone

Enter a phone number

Phone type Phone type

Email address Email address

Enter a valid email address

Email type Email type

Send me email updates & newsletters

Date of birth

Month Month

Enter a month

Day Day

Enter a day

Year Year

Enter a year

Background

Languages Languages

Address

Home Work

Address Address

Enter an address

Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

City City

Enter a city

Country/region Country/region

Enter a country

State State

Enter a state

ZIP code ZIP code

Enter a zip

Send me lettermail updates & newsletters

Experience

Skills Skills

Groups you belong to Groups you belong to

Describe any previous experience you've had Describe any previous experience you've had

Enter previous experience

Availability

Indicate the times that you're available to volunteer

	Morning	Afternoon	Evening
Sun
Mon
Tues
Wed
Thurs
Fri
Sat

Select available times

How often you'd like to help How often you'd like to help

Select a frequency

Total hours to pledge Total hours to pledge

Specify hours to pledge

Additional details

T-Shirt size T-Shirt size

Enter a t-shirt size

Dietary restriction Dietary restriction

Allergies Allergies

Physical limitations Physical limitations

Please read the following agreements carefully. Each section outlines important information about your participation as a volunteer. By checking “I agree” below each section, you acknowledge that you have read, understood, and accepted the terms.

Enter a response

I understand that if I plan to volunteer more than three times or will be working directly with clients, I must complete a background check. United Rehabilitation Services currently offers this service free of charge.

Enter a response

I give permission to United Rehabilitation Services of Greater Dayton (URS) to photograph or record me and use these images or recordings for promotional or educational purposes, with or without my name, unless I revoke this consent in writing.

Enter a response

I understand that URS is a nut-free facility and agree not to bring peanuts or tree nuts into the building.

Enter a response

I understand that URS complies with HIPAA and that I must protect the privacy and confidentiality of all client health information. I will not share, discuss, or release any personal health information without authorization.

Enter a response

I affirm that I have never been convicted of or pled guilty to offenses outlined under Section 109.572 of the Ohio Revised Code and Rule 5123:2-2-02 of the Department of Disabilities. I understand a signed Statement will be required.

Enter a response

I confirm that I have read, understood, and agree to all terms and policies outlined above.

Enter a response

Emergency contact

Relationship Relationship

Select a relationship

First name First name

Enter a first name

Last name Last name

Enter a last name

Phone Phone

Enter a phone number

Phone type Phone type

Email address Email address

Enter a valid email address

Email type Email type

Confirmation

Click Continue to review our terms and conditions

Continue