Please fill out completely before submitting it. We cannot process your application for volunteer service unless all pertaining sections are completed and we receive all supporting documentation listed within this application.
PRIMARY PRACTICE INFORMATION (nurses included):
SECONDARY PRACTICE INFORMATION, if applicable:
FACILITY AFFILIATIONS (nurses included): (List current hospital/health system affiliation where you have been credentialed and privileged)
LICENSURE & REGISTRATIONS *(List all active professional licenses):
IMMUNIZATION HISTORY (Please provide dates of immunization):
I affirm that: I have never been convicted of a felony, I have never been charged with sexual harassment, I have not and will not provide patient care under the influence of drugs or alcohol, I do not have any communicable disease, and I further understand that if at any time I am considered to be infectious I will notify the Clinic's medical director and/or executive director.
In making this application, I acknowledge my obligation to: fulfill my responsibilities to provide continuous quality care to patients of the Clinic; make decisions as appropriate to the patient's needs; to maintain practice knowledge and skills through continuing education opportunities; abide by the bylaws, rules and regulations, policies and procedures of the Clinic; participate in and cooperate fully with the Quality Assurance Program and all programs to improve quality and reduce risks.
I agree to: participate in the review of records and documents relating to patient care and services; subject my performance to review by the Clinic and its representatives for the purpose of improving the quality of care and services and reducing risk.
I hold the Clinic and its representatives free of all liability for such actions.
In consideration of my volunteerism with Medical Mission Adventures, Inc. (hereafter referred to as MMA), I recognize that confidentiality is vital to protect the privacy of our patients and staff. Also included are any issues that relate to the patient and staff. Therefore, I agree to respect and maintain the confidentiality of all discussions, deliberations, records, and other information generated in connection with all MMA activities whether oral, electronically, or written, and I understand that by signing this agreement I am binding myself by contract to maintain such confidentiality. I agree that I will not make any voluntary disclosure of such confidential information outside of MMA, limit dissemination of such confidential information to only those MMA employees/volunteers who have a need to know to perform their assigned tasks, not copy confidential information or any portion thereof except as required under my assigned duties, and return all such confidential information and any copy thereof upon termination of my service with MMA.
I understand and agree that MMA shall have the right to seek and obtain from a court of competent jurisdiction, in an action for that purpose, an order and /or a judgment enjoining and prohibiting me from voluntarily disclosing confidential information in violation of this agreement. I agree that it is impossible to measure in money the damages which would result from my disclosure of confidential information in violation of this agreement and that irreparable injury would be caused thereby to MMA. I hereby waive any claim of defense that MMA has an adequate remedy at law, and I consent to the imposition of injunctive relief to prevent a breach of this agreement. MMA shall be entitled to recover attorney's fees and court costs from me in any such action in which they are successful.
I understand that my obligations under this agreement will continue whether or not my service with MMA is terminated voluntarily, or with or without cause and shall continue to bind my successors, heirs, andassigns.
This agreement may not be changed in any detail by any verbal statement, representation, or other Agreement made by any other MMA employee or volunteer, or by any written document signed by any MMA employee/volunteer other than a MMA officer.
The law of the state of California will govern the interpretation, validity, and effect of this contract, without regard to the place of making or the place of performance.
Further I state that: (a) I am legally competent to execute this agreement and I am above the age of eighteen (18) years of age; (b) No promise or agreement which is not expressed has been made to me in executing this release; (c) I am not relying upon any statement or representation of any agent of the parties being released; (d) I understand that the terms of this release are contractual and not mere recital; (e) I have had the opportunity to consult with legal counsel regarding the effect of this agreement and release should I so desire; and (f) I have fully read this release and have agreed to as my own free act and will.
I give my permission to Medical Mission Adventures, Inc. to verify any information necessary pertaining to my volunteer application. I hereby release from liability Medical Mission Adventures and all its representatives for their acts performed while evaluating my application, credentials and qualifications, including the gathering of necessary information from primary sources for the verification of professional
I hereby release from any liability any and all individuals and organizations that provide information to Medical Mission Adventures or its representatives concerning my professional competence, character, ethics, credentials and other qualifications for employment and/or privileges, and I hereby consent to the release of
As applicable, I hereby accept that I will abide by the requirements for medical malpractice coverage for the Federal Tort Claims Act. I will cooperate fully in all measures to improve quality and reduce risks, and with any investigations and defense of liability claims.
I understand that I have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications, and for resolving any doubts about such qualifications. I fully understand that any misstatements or omissions in the application constitute cause for denial or termination of privileges. All information submitted by me in this application is true to the best of my knowledge.
Thank you for applying to volunteer with Medical Mission Adventures!