Name*Email Cell Phone*Home PhoneDOB*Address*State*City*Zip Code*List any Special Skills you have that may be used in the clinicWhat do you expect to gain from your volunteer experience?List any previous volunteer experiences :Have you ever been convicted of a felony?*NoYes Emergency ContactsNameRelationshipPhoneNameRelationshipPhone EducationHigh SchoolGrad date/projected grad dateCollegeMajorGrad date/projected grad dateGraduate schoolMajorGrad date/projected grad date License/CertificationLicenseState/License #Exp DateLicenseState/License #Exp Date Work Related ReferencesEmployer NameOccupationPhoneEmployer NameOccupationPhone CONFIDENTIALITY AND NON-DISCLOSURE ADDENDUMIt is the legal and ethical responsibility of all Maliheh Free Clinic staff and volunteers to protect personal and confidential patient information, including financial information, in accordance with state and federal laws. Unauthorized use, disclosure, viewing of or access to confidential information is in violation of state and federal laws and may result in personal fines, civil liability and licensure and/or criminal sanctions. As an authorized user of confidential patient information, I will access, use or disclose confidential information only in the performance of my duties, when required or permitted by law and disclose information only to those who have the right to receive that information. I will not knowingly discuss any confidential information within the hearing of persons who do not have the right to receive the information. I will protect confidential information which is disclosed to me in the course of my relationship with the Maliheh Free Clinic. I understand that violation of confidentiality is cause for disciplinary action, including immediate dismissal.Volunteer signature*Date*WAIVER OF LIABILITY AND HOLD HARMLESSI have made an application to Maliheh Free Clinic to perform volunteer services. I understand that should I become injured in any way while performing any service, that Maliheh Free Clinic does not cover any injury by worker’s compensation insurance. Furthermore, as a condition of being approved and accepted as a volunteer I hereby waive any liability of Maliheh Free Clinic and hold Maliheh Free Clinic harmless from any and all injuries I may incur past, present or future while performing any volunteer services. Volunteer signature*Date*PHOTO RELEASEI give my permission to the Maliheh Free Clinic to take and use photographs, audio and video recordings and facsimile images of me without compensation for promotional activities. I further agree to hold Maliheh Free Clinic harmless from all claims arising from the use of said photographs, audio and video recordings and facsimile images when used within the scope described above. Volunteer signatureDateCommentsThis field is for validation purposes and should be left unchanged. Printable Form
