CCHC Volunteer Application

CCHC Volunteer Application
Contact Information
Name (full legal name)
Address

Street Address

Street Address Line 2

City ST ZIP CodeState / Province

Postal / Zip Code
Home Phone
Cell Phone
E-Mail Address
example@example.com
Contact Preference
Date of Birth

MonthDayYear
Date
Gender
Place of Employment
Position
Description of Responsibilities
Educational Background
Are you a Medical Professional?

YesNo
Do you have Hospital Credentials?

YesNo
If so, where?
Please list any foreign languages you speak and your level of fluency.
Do you have any health conditions that limit your ability to volunteer?

YesNo
If yes, please explain.
During which hours are you available for volunteer assignments?

Weekday morningsWeekday afternoonsWeekday eveningsWeekend morningsWeekend afternoonsWeekend evenings
Tell us which areas you would like to volunteer in (responses with an asterisk require a current North Carolina license)

Physicians*CMAs*Phlebotomists*Physician Assistants*Optomestrists*Nurse Practitioners*Dentists*Nurses*Physical Therapists*Data Entry AssistantsInterpretersAdministrative Assistants
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact E-Mail Address
example@example.com
Volunteer Statement of Ethics; Confidentiality of Information

Please read the statement and sign in the box below.
As a volunteer with Charlotte Community Health Clinic, I pledge to use my skills to the best of my ability in rendering care or assistance to patients, or while serving in my capacity as a Charlotte Community Health Clinic volunteer. I will strive to maintain a high level of compassion and understanding, and will treat all patients with respect and in a courteous manner. I understand that all aspects of patient care are STRICTLY CONFIDENTIAL and are never to be discussed outside the Clinic, with friends, family or others. Patient information may never be released to anyone, verbally or in writing, except (i) as necessary to render patient care or for the Clinic’s operations in accordance with the Clinic’s policies regarding patient information, or (ii) by written permission by the patient specifying to whom the information can be disclosed and the scope of the disclosure.
Name (printed)
Signature*

Clear
Witness
Date

MonthDayYear
Date
Volunteer Release of Information for Photography and Recordings

Please read the statement and sign in the box below.
I herby give my permission for pictures and audio and video recordings to be taken for Charlotte Community Health Clinic. I permit these photographs, films or recordings to be released to the news media or used for other public relations or educational purposes for Charlotte Community Health Clinic.

I release Charlotte Community Health Clinic from all liability resulting from the taking and authorized use of photographs, films or recordings.
Please check this box if names are not to be used publicly to identify the photographs, films or recordings.
Name (printed)
Signature*

Clear
Witness
Date

MonthDayYear
Date
Health Survey Questionnaire
Volunteers must be in overall good health to be able to function as a volunteer at Charlotte Community Health Clinic. Minimal lifting, standing, sitting and walking are part of the job description of the volunteer.
Health Screening
Known medical conditions
Known allergies
Medication routinely taken
TB Skin Test
Tuberculosis skin testing (PPD) is required for all volunteers. If you have tested negative in the past year, the Clinic will accept those results in writing from the agency that performed the testing. Testing is done one time and then again if there is an exposure to Tuberculosis.

PPDs are done by the clinical staff on Monday and read Thursday at 11:00 am. You will be directed on what day to return at the time of your PPD.
Date of last PPD (if ever)

MonthDayYear
Date
Result of last PPD (if ever)

PositiveNegative
Date of last chest X-Ray (if ever)

MonthDayYear
Date
Results of last chest X-Ray (if ever)
Signature*

Clear
Date

MonthDayYear
Date
Commitment to Volunteer

Please read the statement and sign in the box below.
Charlotte Community Health Clinic loves and appreciates its volunteers! The Clinic could not operate without you.

Every volunteer that we recruit requires a commitment of time and resources of the Clinic, including the cost incurred to conduct TB testing, and the time required of our staff to recruit and train new volunteers. We estimate that it takes 56 hours of volunteer time by each volunteer to recoup the Clinic’s investment in each volunteer. Therefore, before volunteering with the Clinic, we ask that you carefully consider your other time commitments and your willingness to dedicate your time to the Clinic.

By signing below you agree and acknowledge that it is your current intent to volunteer at least 56 hours at the Clinic.
Signature*

Clear
Date

MonthDayYear
Date
Authorization for Background Check

Please read the statement and sign in the box below.
In connection with my employment at Charlotte Community Health Clinic, I hereby authorize the Clinic and all of its agents to request and receive any information and records concerning me, including, but not limited to, criminal history, driving, employment, military, civil and educational data and reports from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies and other entities, including my present and previous employers. This authorization shall remain on file for the duration of my employment and will serve as ongoing authorization to procure information at any time.

Prior to making any adverse decision with regard to employment based on information from the report, the Clinic will provide me with a copy of such report and a description in writing of any legal rights I may have (if any) in connection with such report and decision.

By signing below, I further release and discharge Charlotte Community Health Clinic, all of its agents and every employee or agent of any of the foregoing, and all individuals and personnel, businesses, private or public entities of any kind, from any and all claims and liabilities arising out of any request(s) for or receipt of information or records pursuant to this authorization or arising out of any compliance or attempt of compliance with such request(s I also authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I acknowledge that I have voluntarily provided the information below and elsewhere in this application and I have completely read, and understand, this authorization. The name listed at the top of this application is my true and complete legal name, and all information is true and correct to the best of my knowledge.
Signature*

Clear
Date

MonthDayYear
Date
Social Security Number
Please list any Residences in the past ten years. Include address, city, state, country, and how long you were a resident there.
Should be Empty:

CCHC Volunteer Application

Contact Information

Emergency Contact Information

Volunteer Statement of Ethics; Confidentiality of Information

Volunteer Release of Information for Photography and Recordings

Health Survey Questionnaire

Health Screening

TB Skin Test

Commitment to Volunteer

Authorization for Background Check