General Information Full Name *
* Home Phone * Work Phone Cell Phone Email *
Are you at least 18 years of age? * If No, are you at least 16 years of age? * Are you connected with someone within Waterfall Clinic? * If yes, please explain: * Why are you interested in volunteering with Waterfall Clinic? * Education Student Status: School/University Course of Study Educational Degrees/Professional Licenses List all Volunteer Tasks you are interested in applying for below. Languages Spoken: Availability
Please indicate all the times you are available to volunteer.
Monday Tuesday Wednesday Thursday Friday Other information you would like us to know about your availability?
(specific time constraints, etc.)
Please Note: Volunteer placement depends on available opportunities that match your skills and interests. Your application will be considered active upon completion and return, including other required supplemental forms and information. Agreements and Signatures Confidentiality Statement
This document is intended for employees, volunteers, students, visitors and business associates. The words patient and client should be viewed as interchangeable. Patient confidentiality is the preservation, in confidence, of all information concerning a client or patient which may be disclosed in a treatment relationship between the patient and medical, dental, pharmacy, social health, mental health, general health care professionals, or other employees of the clinic. All treatment records and other personal information concerning individual patients are confidential. Under Oregon law, Waterfall CHC may be legally liable for your actions that are within the course and scope of your duties as a volunteer. However, improper disclosure of confidential information could be considered not to be within the course and scope of your duties. As a result, Waterfall CHC could refuse to defend you in any legal action that might be brought by a client for violating the patient or client’s confidentiality. Under Waterfall CHC policy, breaches of confidentiality can result in immediate dismissal. Being informed of the preceding, as a volunteer, you agree that you will at all times keep confidential and will not disclose or furnish to anyone, other than to other employees or agents of Waterfall CHC (but only as appropriate and necessary): 1) the names or addresses of any of Waterfall CHC’s patient’s; 2) the diagnosis, treatment, and results thereof of any medical care furnished to any Waterfall CHC patients, except as authorized in writing by the patient or as may otherwise be prescribed by law. In addition, as a volunteer, you will at all times keep confidential and will not disclose any information received during the course of your volunteerism (or during your association with Waterfall CHC with regard to the personnel, financial or other proprietary information of Waterfall CHC, its employees, or its patients, except to entities with a bona fide “need to know” for service delivery, government licensing authorities, or, if required by the terms of a contract or grant, to representatives of the contracting agency or grantor. As a volunteer, you also agree that the two preceding paragraphs shall be a continuing agreement and shall survive any termination or expiration of the relationship between you, as a volunteer, and Waterfall CHC.
I have read and fully understand the information above. *
My initials below certify I have read and fully understand the information above. I further understand and agree I have a duty to abide by the laws and policies governing the preservation of confidential information and that I will abide by those laws and policies and that failure to do so may result in disciplinary action including dismissal. Waterfall retains the right to dismiss a volunteer with or without cause.
As a volunteer of Waterfall CHC, you understand that you will not receive compensation for services you provide.
You agree and understand that activities occurring offsite in which you participate as a Volunteer Provider on behalf of the Waterfall CHC will be documented.
As a volunteer of Waterfall CHC, you agree that you will participate in and complete all required organizational training assignments within allotted timeframes. Failure to do so may result in a temporary suspension and/or dismissal from Waterfall CHC in your capacity as a volunteer.
As a volunteer of Waterfall CHC, you agree to undergo a background check in the same capacity as an employee prior to service. Failure to do so may result in a temporary suspension and/or dismissal from Waterfall CHC in your capacity as a volunteer.
Drug-Free Workplace Commitment *
Waterfall CHC is committed to providing health care of the highest quality to its patients. Controlled substance/ Alcohol abuse can critically hinder employee work performance and judgment, seriously jeopardizing the commitment. Therefore, the unlawful
manufacture, distribution, dispensation, possession, or use of controlled substances is strictly prohibited in the workplace, Upon review of the priorities mentioned above, I, as a volunteer/student/visitor/business associate will actively participate in the maintenance of a drug-free workplace at Waterfall CHC. I understand that more information about counseling, assistance2, rehabilitation programs or services is readily available from the Human Resources Office on request. I agree to notify the Waterfall Office within 5 days of any criminal drug conviction as an initial and continuous condition of volunteerism. I further understand that Waterfall CHC may conduct reasonable suspicion drug testing if warranted and that the testing will be done only in accordance with the conditions listed above.
General Release *
In consideration of Waterfall CHC arranging a volunteer assignment for me, and with the intention of binding myself, my heirs, legal representatives, successors and assigns, I hereby expressly RELEASE AND FOREVER DISCHARGE Waterfall Clinic Inc., dba Waterfall Community Health Center, its officers, directors, employees, volunteers, agents, legal representatives, insurers, successors, and assigns from any and all claims, demands, damages, liabilities, and causes of action that I now have or may in the future have, whether known or unknown, of whatsoever nature, relating to or arising out of my selection as a volunteer by, or my service as a volunteer with, Waterfall CHC whether or not due to Waterfall CHC’s negligence, strict liability or any other breach or fault. This included, but is expressly not limited to, death, bodily injury, personal injury, property damage, loss or theft of property, economic loss, or any other damage, loss, or cost. This document shall be construed according to the laws of the State of Oregon. If a dispute should arise with respect to the meaning of any of the terms of this document, the rule of construction that a document is construed against the party preparing such a document shall specifically not be applicable to the interpretation of this document. This General Release represents the entire agreement of the parties hereto and supersedes any and all prior or contemporaneous oral or written understandings, statements, representations, or promises. All of the terms hereof are contractual and not mere recitals. I acknowledge that I have carefully read this General Release, know and understand the contents thereof, and that this document was freely and voluntarily executed. I acknowledge that I was given the opportunity to seek independent legal counsel on any and all matters herein before I signed this General Release.
Applicant Signature *
I hereby acknowledge that I have read and understand the above statements. I certify that all answers to questions in this application and all additional information I may have submitted are true and complete to the best of my knowledge. I understand that giving false information, misrepresenting facts, and material omissions may be grounds for denial of service or discharge.
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