Please complete this application form if you are interested in becoming a Sea Mar Community Health Centers volunteer. Once you complete the form, click the submit button at the bottom.


IMPORTANT: Due to a high volume of applicants, it may take up to three weeks to process your application. Thank you for your patience!


Personal Information

Please provide the required information.



Demographic Information

This section is optional. Any information provided will be used for statistical purposes.



Assignment Preferences

To see a list of current Sea Mar volunteer opportunities and the requirements and skills needed for each, copy and paste the below link into your web browser:

http://www.volgistics.com/ex/portal.dll/OD?FROM=25455



Skills


Availability

Please indicate the days and times you are available to volunteer (from time you can clock in and out). NOTE: You must be able to volunteer at least 4 hours per week for 6 months.


Volunteer opportunities are only available Mon-Fri; 8am-5pm.



Other


Criminal History


Why do you want to volunteer?

Tell us why you want to volunteer at Sea Mar. What do you hope to gain with this experience?



Volunteer Agreements

CONFIDENTIALITY STATEMENT

All patient Protected Health Information (PHIwhich includes patient medical and financial information), employee records, financial and operating data of the practice, and any other information of a private or sensitive nature are considered confidential. Confidential information should not be read or discussed by any employee unless pertaining to his or her specific job requirements. Examples of inappropriate disclosures include:


" Employees discussing or revealing PHI or other confidential information to friends or family members.

" Employees discussing or revealing PHI or other confidential information to other employees without a legitimate need to know.

" The disclosure of a patients presence in the office, hospital, or other medical facility, without the patients consent, to an unauthorized party without a legitimate need to know, and that may indicate the nature of the illness and jeopardize confidentiality.


The unauthorized disclosure of PHI or other confidential information by employees can subject each individual employee and the practice to civil and criminal liability. Disclosure of PHI or other confidential information to unauthorized persons, or unauthorized access to, or misuse, theft, destruction, alteration, or sabotage of such information, is grounds for immediate disciplinary action up to and including termination.


EMPLOYEE CONFIDENTIALITY STATEMENT

I hereby acknowledge, by checking the "I Agree" box below, that I understand that the PHI, other confidential records, and data to which I have knowledge and access in the course of my employment with Sea Mar is to be kept confidential, and this confidentiality is a condition of my employment. This information shall not be disclosed to anyone under any circumstances, except to the extent necessary to fulfill my job requirements. I understand that my duty to maintain confidentiality continues even after I am no longer employed.


I am familiar with the guidelines in place at Sea Mar pertaining to the use and disclosure of patient PHI or other confidential information. Approval should first be obtained before any disclosure of PHI or other confidential information not addressed in the guidelines and policies and procedures of Sea Mar is made. I also understand that the unauthorized disclosure of patient PHI and other confidential or proprietary information of Sea Mar is grounds for disciplinary action, up to and including immediate dismissal.


VOLUNTEER SERVICES AGREEMENT

The volunteer services agreement is entered into by myself and Sea Mar Community Health Centers. I agree to comply with all of Sea Mar Community Health Centers policies and procedures and report to work on a timely and consistent basis. I will commit to a minimum length of service of four hours weekly for three months. I will abide by Sea Mar Community Health Centers patient code of confidentiality in regards to patients records, treatment and other related information. My dress and conduct will reflect the best of Sea Mar Community Health Centers ethical and professional standards. I understand that if I miss two of my scheduled volunteer shifts, without adequate prior notification, I give Sea Mar Community Health Centers the right to dismiss me from my volunteer service. I understand that it is my responsibility to obtain information from my Site Coordinator regarding my duties and responsibilities at my volunteer site.


CRIMINAL HISTORY

I understand that any offer of volunteer placement is contingent from satisfactory results of a criminal background check. I authorize the investigation of all statements obtained in this application for volunteer placement. I understand that misrepresentation or omission of facts called for hereon will be sufficient cause for cancellation of consideration for volunteer placement or dismissal from the agencys service if I have been placed.

I agree that Sea Mar shall not be held liable in any respect if any volunteer placement offer is not tendered, is withdrawn, or is terminated due to falsity of the statements and answers in this application form.

I am advised that in compliance with the Fair Credit Reporting Act, a routine investigation may be made concerning my character, general reputation, personal characteristics, and mode of living. I have the right to make a written request, within a reasonable period of time, for a summary disclosure of the nature and scope of the investigation.

I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENT AND UNDERSTAND IT.