Please complete this application form if you are interested in becoming a volunteer at CPCN - Burleson Medical Clinic.  Once you complete the form, click the Continue button at the bottom.


Volunteer Information


Education, Licensure & Certifications


Additional Skills

In which of these areas do you feel you have moderate to excellent skill? Check all that apply.



Availability

Please indicate the days and times you are usually available to volunteer.



Volunteer Opportunities

The following volunteer opportunities may currently be available.  Use this list to rank your top three choices.



Emergency Contact

In the event of an emergency whom should we notify?



ACKNOWLEDGEMENTS & RELEASES

CONFIDENTIALITY STATEMENT:

All information regarding the CPCN - Burleson Medical Clinic, 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.

Your agreement 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 see the Administrator.

A copy of the HIPAA Policy can be found in the Volunteer Handbook. 


VOLUNTEER APPLICATION STATEMENT:

I understand and agree that submitting this application form does not automatically register me as a CPCN - Burleson Medical Clinic volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.


By submitting this form, I attest that the information I have provided on this form is true and accurate.




RELEASE AND WAIVER OF LIABILITY:

I HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge CPCN - Burleson Medical Clinic (CPCN) and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, cause of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation in the events and activities conducted by, on the premises of, or for the benefit of CPCN, provided that this waiver of liability does not apply to any acts of gross negligence or willful misconduct by CPCN.

I understand that the activities and functions in which I participate may be considered [but do not have to be] of a volunteer nature, or for the benefit of a 501(c)3, and/or dangerous and may cause grievous injuries, including bodily injury, damage to personal property, and/or death. On behalf of myself, my heirs, my assigns and next of kin, I waive all claims for damages, injury and death sustained by me or my property that I may have against the aforementioned released party to such activity.
I assume any risk, and take responsibility and waive any claims of personal injury, death or damage to real or personal property including, but not limited to any sickness, volunteer activities, community events and/or engaging in organizational functions and activities for non-profit engagements or functions and fundraisers or other related activities on or off the premises.

I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing release and waiver of liability and hold harmless agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least 18 years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by the same.

Please review the following:
Medical treatment: The volunteer does hereby release and forever discharge CPCN from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with the volunteer’s activities with CPCN.
Insurance: The volunteer understands that, except as otherwise agreed by CPCN in writing, CPCN does not carry or maintain health, medical or disability insurance coverage for any volunteer.
Photographic release: The volunteer does hereby grant and convey unto CPCN all right, title, and interest in any and all photographic images and video or audio recordings made by CPCN during the volunteer’s activities with CPCN, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings.