Volunteer Candidate Registration Form

Name*

First Name Last Name

E-mail

Birth Date*

Month Day Year

Phone Number*

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Emergency Contact*

First Name Last Name

Emergency Contact Phone*

Area Code Phone Number

Please indicate why you are requesting to volunteer with us:*

I need volunteer / observation hours to apply to an occupational therapy program.I am considering occupational therapy as a career.I would like to volunteer my time simply to help others and my community.I need volunteer hours for my church.I need volunteer hours for middle / high school.

Out of an abundance of caution for the safety of our clients, Caterpillar Playground requires all volunteers to submit a background check in the form of a Live Scan report. Once we have agreed to begin a volunteering schedule, we will provide you with a Live Scan form, which can be processed at several locations. Unfortunately, we are not in a position to cover the cost of Live Scans for our volunteers, meaning that you are responsible for the cost of the scan. As of 05/05/2022, the total cost for Live Scan submission is approximately $79.*

I agree and understand that I must provide at Live Scan report at my own cost in order to become a volunteer with Caterpillar Playground Occupational and Physical Therapy.I have recently completed a Live Scan for another facility and can obtain and provide a copy.

Caterpillar Playground provides medical services to children. This means that we maintain confidentiality according to HIPAA rules. Our therapists, staff, and volunteers must all abide by these rules.

We may not discuss or disclose any client's information via written, verbal, or electronic means in any way that could risk the client's confidentiality. When you begin volunteering with us, you will be provided with a copy of our HIPAA agreement.

We encourage you, as a valued volunteer, to read about HIPAA guidelines prior to beginning your time with us.

I understand that I must follow the confidentiality guidelines under HIPAA law as well as the policies of Caterpillar Playground. In the event that I do something to risk a client's confidential information, my volunteer work at this facility may be immediately terminated.*

I agree

We, at Caterpillar Playground, are very grateful for our volunteers, and we appreciate your gift of time and talent! Following are some ways we may ask you to help while you're with us:

Clerical tasks, such as filing or answering phone calls, cutting out or laminating materials
Assisting therapists in various ways:
- keeping notes or data
- assisting with safety (i.e. standing near clients to prevent falls)
- assisting with turn-taking activities with children
- assisting with positioning of clients
Tidying the clinic
Preparing or gathering materials as guided by therapist
Sanitizing surfaces, equipment, or items
Greeting and checking in clients, and ensuring they complete necessary screens or forms
Organization tasks

Do you have any physical limitations or medical restrictions that we should take into consideration when asking you to perform tasks? We can adjust our requests as needed.*

No limitations or restrictions

While you are under no obligation to volunteer with us, we can best plan services for our clients when we have a clear schedule of when to expect you.

Reliability is important for our clients, so we ask that a schedule be set and that you let us know in advance if you are unable to be here.

Please let us know your availability and how much of your time you would like to share.

How many hours a week would you like to volunteer with us?

How many hours would like to volunteer in TOTAL?

Please mark days and times you are available:

	Mondays	Tuesdays	Wednesdays	Thursdays	Fridays
9:30-12:00
12:00-2:00
2:00-4:00
4:00-6:00
Variable, will discuss in person

Thank you for offering your time!

We'll contact you as soon as we can, but feel free to follow up with a phone call or email.

Please share anything else you would like us to know:

Volunteer Registration