Volunteer Interest Form

Thank you for your interest in volunteering at Crossings Community Clinic. The following form is not an application for employment but is only for those seeking to volunteer. This screening form asks some very personal and private questions. Be assured, the information contained in this screening form will be treated with the utmost confidentiality and respect. No one will have access to this form without proper authorization. The questions contained herein are not intended to offend but rather to create a secure and safe environment for our volunteers, patients, and staff. Once you have completed the form, click the submit button at the bottom.

Clinic Mission Statement:

To humbly proclaim the message of Jesus by serving the physical, emotional, and spiritual needs of the uninsured.

Statement of Faith:

We are a Christ-centered clinic committed to live by FAITH, to be a voice of HOPE, and to be known by LOVE.

"But in your hearts revere Christ as Lord. Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect..." 1 Peter 3:15

"I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me." Matthew 25:36

Volunteer Statement of Commitment:

1. Demonstrate the love of Christ through my actions by serving others.

2. Use my spiritual gifts and talents to encourage, uplift, and serve those in need.

3. Provide hope to those I serve as I introduce them to Jesus Christ.

4. Continually grow and strengthen my faith as I minister to others.

I understand the Volunteer Commitment:

General Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

Date of birth:

Gender:

Are you active in a local church:

Do you consider yourself a Christian?:

If yes, what is the name of the church?:

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email. We will make every effort not to send you any unwanted email and will not give your email address to any third parties without your consent. Use the checkboxes below to select the kinds of email you would like to receive from us. At a minimum, please check the electronic newsletter to receive updates on general volunteer needs.

Email address:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

General Information

Schedule reminders

Emergency Contact

In the event of an emergency, who should we contact on your behalf?

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Availability

Please indicate the days and times you will most likely be available to volunteer.

Background Information

Please review the following statements carefully and respond to the group of questions with a yes or no statement. If you answer yes to any, please explain below.

1. Have you ever had, or has anyone ever suggested that you have, an addiction to drugs, alcohol, pornography, or any other addiction?

2. Have you ever been arrested, convicted or pled guilty or no contest to a criminal offense of any kind?

3. Have you ever been charged with, alleged to have, or have you ever committed any act of neglecting, abusing, molesting, or battering any child or adult? Or have you had any kind of a relationship with a minor that brought you sexual gratification?

4. Have you ever been treated for a psychiatric disorder?

5. Is there any circumstance or pattern in your life which would make it inappropriate for you to serve or which would compromise the integrity of Crossings Community Clinic?

Background Screening Questions Y/N:

Drivers License State and Number:

Social Security Number:

If you've answered yes to any of the above questions, please explain.

Skills and Preferred Assignments

We intend to provide every volunteer with an experience that is both meaningful and fulfilling. Please help us to maximize your time with us by listing any special skills you are comfortable performing and/or your desired assignment preferences and we will do our best to match you with those opportunities.

Please list your current employment, any professional license and/or certification information below, if applicable.

Education, Licensure, Certifications, Employment

Please list your current employment, any professional license and/or certification information below, if applicable.

Students and Service Hours

Complete this section if you require volunteer hours for school or any other community requirement.

Personal References

List two people you know who meet the following criteria:

1. Over 18 years old,

2. Not related to you,

3. Has known you for more than 2 years, and

4. Possesses a definite knowledge of your character.

1

2

First name:

Last name:

City:

State:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Confidentiality

I understand that I may, during the course of my work with Crossings Community Clinic, come in contact with confidential patient information of both a medical and personal nature. It is for this reason that I, the undersigned, do hereby affirm that I will:

1. Protect and safeguard this confidential information from any oral and/or written disclosure in every instance.

2. Not release confidential information from any medical record source to any unauthorized person while at Crossings Community Clinic or after I complete my volunteer tenure.

3. Verify the authorization of any and all persons requesting any patient information.

4. Restrict my own access to confidential information to that information which is essential to the proper completion of my immediate job responsibilities.

I understand that all policies on confidentiality apply equally to information stored on paper records and to that stored electronically or on any other media.

Finally, I understand that any misuse of information found in the patient’s medical record or violation of the principals of patient confidentiality, whether intentional or due to neglect on my part, will be grounds for immediate disciplinary action, up to and including termination.

Statement of Confidentiality:

Model Release

I hereby authorize and permit Crossings Community Clinic and those operating under its authority the right and permission to copyright and/or publish photographic and/or video images, audio recordings or written statement of me and/or my minor child in which I/he/she may be included, in whole or in part, for publicity, advertisement, stock use or other purposes.

I hereby waive any right that I/he/she may have to inspect and/or approve the finished product or the advertising copy that may be used in connection with such images, or the use to which it may be applied.

I hereby release and agree to indemnify and hold harmless Crossings Community Clinic and those operating under its authority from liability for the use of these pictures or video. I warrant that I am of full legal age and that I have read and understand the contents of the release and authorization.

Model Release:

Applicant's Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for this position/work. I authorize the release of the information contained in this application, on a confidential, need to know basis, to any ministry at Crossings Community Clinic in which I seek a position (volunteer or compensated). In consideration of the receipt and evaluation of this application by Crossings Community Clinic, I hereby release any individual, church, youth organization, charity, reference or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature, which may at any time result to me, my heirs or family, on account of compliance or any attempts to comply, with this authorization. To uphold the confidentiality of the references, I waive any right that I may have to inspect any information provided about me by any person or organization, but I may contact Crossings Community Clinic to inquire about information provided about me.

Also, I hereby request and authorize the release of any information which pertains to any record of convictions contained in law enforcement files or in any criminal file maintained on me whether local, state or national. I hereby release local, state and national law enforcement agencies from any and all liability resulting from such disclosure.

Crossings Community Clinic reserves the right to conduct additional background checks in the future for volunteers involved in long-term service.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand.

I Agree

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