HELPING HANDS HEALTH AND WELLNESS CENTER

VOLUNTEER INFORMATION FORM

Date: _____________________________

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

City: _____________________________________________ State: _______ Zip: ___________________

Phone: _____________________________________ Cell: ____________________________________

Email: _______________________________________________________________________________

What job(s) would you like to volunteer for? :

___greeter ___community resources/social services

___admissions/discharges ___ Providing meals or snacks for volunteers/patients

___nurse assessment ___prayer team

___physician assistant ___pharmacy

___physician ___other_____________________________

The clinic is open four times a month on two Fridays and two Thursdays, how often would you like to volunteer?: ___________________________________________________________________________

Languages other than English you speak: ___________________________________________________

Could you interpret this language if asked? Yes No

What Medical License/certifications do you have, if any?: ______________________________________

Volunteers must provide a copy of all licenses and certifications to put on file.

Do you have CPR certification? Yes No Date: ______________________________________________

Copy of certification will be needed to keep on file

Present Church: _______________________________________________________________________

References Name and Phone #:___________________________________________________________

Have you ever been convicted of a felony? : Yes No

Simple Background Checks may be done, do we have your approval: Yes No

Work Experience: ______________________________________________________________________

Volunteer Experience: __________________________________________________________________

Reason you would like to volunteer: _______________________________________________________

In case of an emergency, contact: name:___________________________ phone:__________________

Our doors will be open to many persons of diverse backgrounds, nationalities and

illnesses. Will you be comfortable with this? Yes No

Tuberculosis or Hepatitis B, are you currently experiencing either of these illnesses? Yes No Have you been treated? Yes No

Have you been tested for TB in the last year Yes No If no, please let us know when you are tested. Have you had Hepatitis B shots Yes No

Signature: ____________________________________________ Date :__________________________

VOLUNTEER CONFIDENTIALITY STATEMENT

Due to the nature of information available through the Helping Hands Health and Wellness Center, it is imperative that each staff member, whether paid or unpaid, understands and is committed to the issue of confidentiality.

As a volunteer of the Helping Hands and Health and Wellness Center, I agree to respect and maintain the confidentiality of all information, whether written or verbal, which pertains to the services provided by the Helping Hands and Wellness Center and to make no voluntary disclosure of such information except to persons authorized to obtain it. I will not discuss or distribute any information pertaining to patient or staff information without the express written consent of the Executive Director or other appropriate authority.

If I encounter a patient outside of the Clinic, I agree not to acknowledge the patient unless first acknowledged by the patient. At no time will I acknowledge to anyone that I know the patient from the clinic. Failure to comply with this policy may result in termination.

Signature of Volunteer_____________________________________ Date: ________________________

Print Name____________________________________________________________________________

RELEASE OF LIABILITY

I,_________________________, (insert volunteer’s name) hereby release and hold harmless the Helping Hands Health and Wellness Center and its agents, employees, representatives, officers and directors, from any and all liability, costs, damages, causes of action suits, and/or claims of any kind or nature (collectively “claims”) related to or arising out of my providing volunteer services for Helping Hands Health and Wellness Center.

This release applies to all claims, whether known or unknown, foreseen or unforeseen, that I have at any time against Helping Hands Health and Wellness Center and its agents employees, representatives, officers and directors.

As indicated by my signature below, I have read and fully understand the terms of this release. If I am under 18 years of age, I have reviewed this release of liability which at least one of my parents/guardians, and my parents/guardians have indicated acceptance of the terms of the release by signing below and signing the Emergency Medical Authorization on the back of this release.

Signature of Volunteer: _______________________________________ Date: _____________________

IF VOLUNTEER IS UNDER 18 YEARS OF AGE

Signature of Parent/Guardian: __________________________________ Date: _____________________

Print Name: ___________________________________________________________________________

Relationship to Volunteer: _______________________________________________________________

Phone Number: ________________________________________________________________________

HBV VACCINE DECLINATION FOR VOLUNTEERS

“I understand that due to volunteering exposure to blood of other potentially infectious material, I may be at risk of acquiring hepatitis B virus (HBV) infection. I decline going to obtain the hepatitis B vaccination on my own at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.

If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I will seek receiving the vaccination series through my private medical provider. I will then give proof of my vaccination series to Helping Hands Health and Wellness Center.”

Signature: ____________________________________________________________________________

Print Name: ___________________________________________________________________________

Date: ________________________________________________________________________________

Printable Version Volunteer Application

The Helping Hands Health and Wellness Center is a member of the Ohio Association of Free Clinics and The National Association of Free and Charitable Clinics

Helping Hands Health and Wellness Center is a 501 (c) (3) non-profit organization

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