MM slash DD slash YYYY
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Best Time and Number to Call:
Please provide a list of all licenses/credentials you hold. Then upload a photocopy of each below.
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
This does not include minor traffic offenses and/or convictions that have been sealed, expunged or statutorily eradicated.
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, 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 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.
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.