Please complete this application form if you are interested in becoming a Debbie-Rand Memorial Service League, Inc. volunteer. Once you complete the form, click the submit button at the bottom.


As a reminder, to be a part of the Adult Program, you must be at least 18 years of age. If you are under the age of 18, please follow the TAV Link on our website.


Please note that we require a six-month commitment.


Name and address


Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.



Availability

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



Email Preferences

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



Photo Release

I hereby authorize the Debbie-Rand Memorial Service League (D-RMSL) to publish the photographs and videos taken of me, and/or our names, for use in the D-RMSL’s printed publications, website and training purposes.


I acknowledge that since participation in publications and websites produced by D-RMSL is voluntary, I will not receive financial compensation.




Emergency Contact


Background

Please fill out the questions below.



Background


References


Screening Questions


Past Involvement


Orientation Date

Please select the day/time that you would like to attend orientation. Please note that orientations are only held on the first Tuesday of every month, at 9:30am, in the Dawson Education Center.



Agreement Section

-It is necessary to show proof of a current photo ID (i.e. Florida Driver's License) prior to beginning as a volunteer.


-Boca Raton Regional Hospital/Debbie-Rand Memorial Service League, Inc. will screen all applicants and applications. Any discrepancies will disqualify an applicant from volunteering at BRRH/D-RMSL.


-I understand that all applicants will be tested for Tuberculosis (TB) and may be subjected to a drug screen.


-I am able to perform the physical and mental duties of the volunteer position.


-I understand and agree that submitting this form does not automatically register me as a volunteer, and that there may be certain qualifications that I must meet.


-I am able to meet the minimum, six-month commitment.


CONFIDENTIALITY/HIPPA POLICY


Boca Raton Regional Hospital, Inc. and its affiliated entities (collectively, BRRH) are committed to maintaining high standards of confidentiality and information security. The responsibility to preserve the confidentiality of information in any form (electronic, verbal or written) rests with each User granted access to BRRH information systems who may have access to Confidential Information, including all Protected Health Information (PHI), Electronic Protected Health Information (ePHI), personnel information, billing and financial information, patient data or medical information, promotional and marketing program information, strategic planning data, business plans, computer passwords/access rights, privileged materials, trade secrets, intellectual property, and other proprietary information relating in any way to BRRH (“Confidential Information”). Any information created, stored or processed on BRRH systems, or systems maintained on BRRH’s behalf by a vendor or other individual or entity, is the property of BRRH, as is any information created by or on behalf of BRRH, whether written, oral or electronic, unless expressly agreed otherwise. BRRH reserves the right to monitor and/or inspect all systems that store or transmit BRRH data, the data stored therein, as well as all documents created by or on behalf of BRRH.


I have read and understand this entire agreement, and I agree to the following:


1. I understand and agree it is my personal responsibility to read, understand and comply with all applicable BRRH policies and procedures, including but not limited to Information Security policies, which are available to me through the BRRH Intranet. I understand that these policies provide important information about the acceptable use of information systems and BRRH email accounts, mobile device usage, data encryption, and other important information. If I am provided access to or receive PHI or ePHI, I also agree to comply with all Privacy policies.


2. I understand and agree that even though I may be granted access to systems which contain large quantities of data and Confidential Information as part of my job responsibilities, my role, or my relationship with BRRH, I am only permitted to access, use, or disclose specific information as necessary to perform my job function, role, or to complete my responsibilities.


3. I understand and agree that I am only permitted to access, use, and disclose information from BRRH system and its components, or its connected systems, if it is for an authorized and permissible purpose in accordance with applicable laws and policies, and may only transmit such information to persons who have the right to receive that information.


4. I understand and agree that the User ID and Password assigned to me are unique and non-transferable and I agree that I will not share my User ID or Password with any other individual, permit another person to perform any functions while logged into a system under my User ID or Password, nor will I perform any function using a system under another person’s User ID or Password.


5. I understand and agree that my approved access and use may be actively recorded, monitored, and/or audited without prior notice (including Internet and e-mail account usage) and that BRRH reserves the right to monitor, review, and record individual User system and network activities (including, but not limited to, the use of personal e-mail accounts) to assure compliance with BRRH’s acceptable use policies. BRRH may permit other business partners or law enforcement to monitor, uses, or record such information as permitted or required by law.


By submitting this form, I understand and agree that my rights to access and use BRRH’s system may be immediately terminated without further notice for violating any terms of this agreement and that such a violation may result in personal liabilities, including but not limited to (as applicable): disciplinary actions up to and including termination of employment, loss of professional privileges, criminal prosecution, civil litigation, referral to appropriate law enforcement authorities, referral to regulatory or licensure authorities, or other remedies as deemed appropriate by BRRH.


BY SUBMITTING THIS FORM, I ATTEST THAT THE INFORMATION THAT I HAVE PROVIDED ON THIS FORM IS TRUE AND ACCURATE.