Please complete this application form if you are a dental professional and are interested in becoming a Bethesda Health Clinic volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information


EMail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email if you prefer not to receive it. Use the checkboxes below to select the kinds of email you would like to receive from us.


Emergency Contact

In the event of an emergency whom should we notify? The second contact is optional.


Assignment Preference

The following dental professional volunteer assignments may currently be available. Click on the assignment you are most qualified for.
If you choose an assignment that requires licensing by the state of Texas, please be prepared to provide such information upon starting date.


Volunteer Experience

If applicable, please briefly describe any previous volunteer experience. If none, please state "None."


Credentials

Please list your specialties, credentials, license numbers, and dental clinic affiliations. This is very important for dental professional applicants. Please provide comprehensive information.


Availability

Are you available to make a commitment of at least 6 months to the clinic with at least four hours per week? If so, please indicate the days and times you are usually available to volunteer.


Church Affiliation

Bethesda Health Clinic is staffed by local churches on Saturdays. If you are interested in volunteering on Saturdays with your church, please select the church from the drop down list.


Volunteer Information Center

We provide an online "Volunteer Information Center" where volunteers may check their schedules, update their information, and receive messages. Please select the password you would like to use to access the online Volunteer Information Center.


Confidentiality Policy

Associates and volunteers are expected to refrain from discussing personal information concerning patients or associates of the Bethesda Health Clinic when on or off duty.

All information and records pertaining to patients as well as associates are private and confidential and only authorized persons who must refer to them as a business necessity shall have access to them. This information must be kept in strict confidence. You must never discuss Bethesda Health Clinic business either inside or outside Bethesda Health Clinic where unauthorized persons could hear it.

Confidentiality is a serious concern and violations of this policy will result in corrective action to include the possibility of separation of employment and/or ability to continue to work as a volunteer for this facility.
I am aware that the Health and Safety Code, ยง81.103, provides for both civil and criminal penalties against anyone who violates the confidentiality of persons protected under the law.


Consent Agreement

I hereby assign all rights to the video or sound recording, stories, articles and/or photographs made of me to Bethesda Health Clinic and I hereby authorize the reproduction, sale, copyright, exhibition, broadcast and/or distribution of said documents to further the mission of Bethesda Health Clinic.

I hereby authorize Bethesda Health Clinic and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but it not limited to the following areas: verification of social security number, current and previous residences, employment history, education background, character references, drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions and any other public records.

I further authorize any individual, company, firm, corporation or public agency to divulge any and all information, verbal or written, pertaining to me, to Bethesda Health Clinic or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation or public agency many have, to include information or data received from other sources. Bethesda Health Clinic and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including but not limited to, addresses and dates of birth.


I Agree

I understand and agree that submitting this application form does not automatically register me as a Bethesda Health 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 the form is true and accurate, that I read and understand the Confidentiality Policy, and that I assign rights and authorizations per the Consent Agreement.