Volunteer Form

Applicant Information
Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Email*
Cell Phone*
Work Phone
Best Time and Number to Call:
Time

: Hours

Minutes

AM/PM
Phone
- Cell Phone
- Work Phone
Are you CPR Certified?*
- Yes
- No

Licenses/Credentials

Please provide a list of all licenses/credentials you hold. Then upload a photocopy of each below.

File
Accepted file types: jpg, png, pdf, doc, csv, xslx, Max. file size: 100 MB.
Check Your Specialty:*
- Physician
- Physician Assistant
- Nurse Practitioner
- Nurse
- Pharmacy
- Dentist
- Patient Advocate/Social Worker
- Medical Assistant
- Phlebotomist
- Translator
- Dental Assistant
- Non-Medical
If Translator, which language?
If Non-Medical, explain.
When are you available to volunteer?
Monday
From To
Tuesday
From To
Wednesday
From To
Thursday
From To
Why do you want to be a volunteer at the Community Clinic of Southwest Missouri?*
Volunteer or Employment Experience
Volunteer or Employment Experience 1
Organization
Position/Major Responsibility
Dates or Service (yy/mm)
From To
Volunteer or Employment Experience 2
Organization
Position/Major Responsibility
Dates or Service (yy/mm)
From To
Volunteer or Employment Experience 3
Organization
Position/Major Responsibility
Dates or Service (yy/mm)
From To
References
Reference 1
Name
First Last
Phone
Reference 2
Name
First Last
Phone
Reference 3
Name
First Last
Phone
Have you ever been convicted of a crime?*
- Yes
- No
This does not include minor traffic offenses and/or convictions that have been sealed, expunged or statutorily eradicated.
Please explain*
Emergency Contact
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
I (Volunteer Applicant Name) desire to volunteer with the Community Clinic of Southwest Missouri as a (Specialty Chosen). I understand and agree to comply with the guidelines/standards set forth by the Clinic.*
I (Volunteer Applicant Name) desire to volunteer with the Community Clinic of Southwest Missouri as a (Specialty Chosen). I understand and agree to comply with the guidelines/standards set forth by the Clinic.
I agree
Liability Disclaimer*
I, and my heirs, in consideration of my participation in the, hereby release Community Clinic, its officers, employees and agents, and any other people officially connected with this organization and/or event, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating with this organization/in this event. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely chose to participate. I understand that the Community Clinic does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur should the need arise as a result of my participation. I understand that I am acting as an independent contractor, and further, I understand that I am not entitled to workers' compensation in the event of injury or death.
I agree
Certification of Application*
I certify that all information submitted by me on this application is true and complete. I understand that if any false information, omissions or misrepresentations are discovered in my application may be rejected and active volunteer status may be terminated.
I agree
Confidentiality Agreement for Persons (Community Service Volunteers, Interns, & Observers)*
All information regarding the Community Clinic of SWMO, its clients, staff, and programs is considered confidential. It is expected that all persons will comply with this policy at all times. All client personal health information is protected under the Health Insurance Portability and Accountability Act. Any unauthorized use of client personal health information is illegal under the HIPAA Act.

Additionally, no person is allowed to take pictures or videos of any client at the Universal Institute. An audio recording of any type is also prohibited.

Your signature below indicates that you understand these laws and policies and agree to comply with the law and policies at all times. If you have any questions regarding confidentiality please ask a director.

Attached is a copy of the HIPAA Staff/Volunteer Training, the Confidentiality Policy, and Procedure and our Social Media Policy for you to review. If you have any questions please ask a Director or Coordinator.

I agree

Applicant Information

Best Time and Number to Call:

When are you available to volunteer?

Volunteer or Employment Experience

Volunteer or Employment Experience 1

Volunteer or Employment Experience 2

Volunteer or Employment Experience 3

References

Reference 1

Reference 2

Reference 3

Emergency Contact

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