UAF Legacy Health Volunteer Application
Name
*
First Name
Last Name
Pronouns
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation/Employer
*
Does your employer have a Charitable Giving Program?
*
Yes
No
Don't know
How did you hear about volunteer opportunities with UAF Legacy Health?
*
Bennion Center
UAF Outreach Event
UAF Website
Social Media
Friends / Existing volunteer
Other
Please select the volunteer programs you're interested in
*
HIV/STI Test Site
Special Events
Outreach
Internship
Given your current schedule, when are you available to volunteer?
*
Weekdays
Evenings
Weekends
Do you speak any languages other than English? If yes, please state which language:
Please describe any other volunteer experience you've had:
*
As a new volunteer, what are your goals and expectations?
*
Please list your emergency contact:
First Name
Last Name
Phone Number
Relationship
Back
Next
Confidentiality Agreement
I understand that, serving as an employee/volunteer of UAF Legacy Health, I may have access to confidential information concerning UAF Legacy Health, its staff members and its clients. This information may be generated within UAF Legacy Health or obtained from outside sources. Improper disclosure of confidential information constitutes a violation of trust and can involve UAF Legacy Health in serious litigation. Access may also be provided to information handling technology, such as computer systems and programs, which UAF Legacy Health has exclusive right to use and/or may be contractually bound to use in prescribed ways. I acknowledge that misuse of information handling technology can constitute a violation of contractual and potentially, a violation of the law as well. Consequently, I agree as a contractual condition of my participation in UAF Legacy Health that I will treat confidential information confidentially and use information handling technology carefully and not for personal gain or in violation of other privacy restrictions or requirements. I further agree not to remove confidential documents, including lists, tapes and computer programs from UAF Legacy Health's premises without prior written authorization from UAF Legacy Health Chief Executive Officer. I understand that any violation of this on my part will be considered grounds for immediate termination and UAF Legacy Health may pursue appropriate recourse to carry out the terms of this agreement.
Signature
*
Liability Waiver
In consideration of the training which I have/will receive from UAF Legacy Health and the trust and confidence which has been placed with me, I agree to the following:I agree to hold harmless and waive any liability against UAF Legacy Health for any accident, injury, loss, damage, etc., that I may incur or suffer while acting as a volunteer of the Foundation, and I agree to assume all risk associated with my volunteer duties. I have obtained the minimum insurance as required by the State of Utah and I accept responsibilities associated herewith.
Signature
*
Photographic release
I hereby give permission to UAF Legacy Health, its representatives and employees the right to take photographic images of me, film/video footage of me, or sound recordings of my voice. I authorize the UAF Legacy Health, its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I understand that I will not receive remuneration of any kind. Moreover, I hereby waive claim to any rights, residuals, fees or other charges in connection with photographs, film/video footage or sound recordings with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. UAF Legacy Health greatly appreciates your participation.
Signature
*
Use of E-signatures
I agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing.
Signature
*
AUTHORIZATION FOR BACKGROUND CHECKS
After carefully reading this Background Check Authorization form, I authorize UAF Legacy Health to order my background report. To maintain the safety and security of our patients, employees, and property, UAF Legacy Health will order a background report in connection with my volunteer application. The types of information that will be ordered include but are not limited to: National Criminal Search, Sex Offender Search, SSN Trace, and Global Watchlist Search. The information may be obtained from private and public record sources. I also authorize the following agencies and entities to disclose to the background check company and its agents all information about or concerning me, including but not limited to law enforcement and all other federal, state, and local agencies; federal, state, and local courts; the military; testing facilities, and any other person, organization, or agency with any information about or concerning me. I agree UAF Legacy Health may rely on this authorization to order background reports, from companies other than the background check company without asking me for my authorization again, as allowed by law. I also agree that a copy of this form is valid like the signed original. I understand that a background check is mandatory to volunteer with UAF Legacy Health in any capacity and agree to pay the associated fee. I certify that all personal information provided is true and correct.
Legal Name
*
First Name
Last Name
Maiden name or other names used
Years used
Signature of Releasor
*
My Products
*
prev
next
( X )
Background Check
If this fee is a financial barrier, please email nico.lockhart-allen@uafhealth.org
$
30.00
Credit Card
Submit
Submit
Should be Empty: