Volunteer Application- Jean B Purvis Community Health Center

JEAN B PURVIS COMMUNITY HEALTH CENTER OF BUTLER COUNTY
VOLUNTEER APPLICATION
Volunteer Position*

ProfessionalInternCommunity
Date*

MonthDayYear
Date
Name*

FIRST NAMELAST NAME
Middle Initial
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*
CITY*
STATE*
ZIP*
PHONE (HOME)*
PHONE (CELL)
EMAIL
example@example.com
EMERGENCY CONTACT*
Relationship*
Emergency Contact Home Phone*
Emergency Contact Cell Phone
STUDENT
COLLEGE/UNIVERSITY
GRADUATION DATE

MonthDayYear
Date
ACADEMIC ADVISOR/CONTACT INFORMATION
FIELD OF STUDY
Are you applying for an academic internship?

YesNo
Semester

SpringSummerFall
Start date

MonthDayYear
Date
EMPLOYED
EMPLOYER
OCCUPATION
ADDRESS
CITY
STATE
ZIP
PHONE (WORK)
FAX
May we contact your employer to verify your professional license and credentials?

YesNo
PROFESSIONAL LICENSE (if applicable)
LICENSE #
PROFESSIONAL LICENSE (if applicable)
LICENSE #
Comments / Special Skills (CPR, Certifications, Interests, etc.)
Volunteer Position(s)*

Clinical ServicesSocial Services/EligibilityGrant WritingDental ServicesOutreach/CommunityAdministrative/OfficeSpecial EventsData Entry/Medical RecordsFundraisingOther
Have you had a PPD (TB) test in the past year?*

YesNo
Upload TB Documentation

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Clinical Volunteers: Have you had a Hepatitis B Vaccination?

YesNo
Upload Hepatitis B Vaccination Documentation

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Do you require any accommodations to perform the duties of the volunteer position for which you are volunteering?*

YesNo
If YES, Please Explain
Have you ever been convicted of a felony? (*A conviction will not necessarily bar you from volunteering)*

YesNo
Clinical Volunteers: Have you ever been required by any licensing board or professional ethics body to surrender your license, or have you ever been found guilty of professional ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence, in any state or country?

YesNo
If YES, Please Explain
Clearances

The Jean B Purvis Community Health Center (CHC) does not directly serve children; however, we do come in occasional contact with children. In keeping with the Commonwealth of Pennsylvania law and the directives of CHC, our volunteers are required: To provide:
To Provide:

- Photo ID

To Obtain:

- Report of criminal history from the Pennsylvania State Police (PSP)

AND

- Child Abuse History certification from the Department of Human Services (Child Abuse)

To apply for your clearances, please visit the sites below. Please note, as a volunteer, there is NO COST to you for the state clearances.

1. The PSP (Pennsylvania State Police) Criminal History Certification - cost $0 (for volunteers)

https://epatch.state.pa.us

(Note: select “New Record Check (Volunteers Only)"

2. PA Child Abuse History Certification from DHS (Department of Human Services) - cost $0 (for volunteers)

https://www.compass.state.pa.us/cwis/public/home

(Note: you will need to create an individual login account, and select Volunteer Having Contact with Children for the purpose of the application)

*PLEASE NOTE* - all clearances will be kept confidential.

** If you already have your clearances from employment and your clearances are less than 3 years old, please submit a copy with this application.
Clearances Upload

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HIPPA/Confidentiality
In compliance with the Health Insurance Portability and Accountability Act (HIPAA), CHC is required by law to protect our patients' privacy. Your signature on this Volunteer Application confirms your acceptance of the policies at CHC including the confidentiality of our patients, staff, and volunteers.
Volunteer Agreement
1. I shall keep confidential all information that I obtain regarding patients, staff, and volunteers.

2. I shall be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of others, and strive to maintain professional quality in my work.

3. I shall at all times uphold the philosophy and standards of the Jean B Purvis Community Health Center (CHC)

4. I understand that CHC reserves the right to terminate my volunteer status as a result of:

a) Failure to comply with clinic policies, rules, and regulations.

b) Unsatisfactory attitude, work, or appearance.

c) Frequent, unexplained absences

d) Any other circumstance(s), which in the judgment of CHC would make my continued service as a volunteer contrary to the best interests of CHC.

All Volunteers: Must provide photo ID and clearances: PSP Criminal History Certification and PA Child Abuse History Certification

Clinical Volunteers: Must include a copy of your Pennsylvania clinical license(s) and/or certification(s) I grant CHC authorization to contact the employer or licensing bureau listed on this application for the purpose of verifying my professional license(s) and/or credentials.

The Jean B Purvis Community Health Center (CHC) does not discriminate against any person because of age, ancestry, color, disability or handicap, national origin, race, religious creed, sex, sexual orientation, or veteran status. It is the policy of CHC to select, develop, and utilize volunteers based on the individual's ability, qualifications, experience, and job performance. CHC will maintain a work environment free of all forms of discrimination, sexual harassment, and intimidation. CHC will comply with the letter and spirit of applicable local, state, and federal statutes regarding Equal Opportunity.

I have read, understand, and agree to the above Volunteer Agreement. I certify that the information I have given is complete, true, and correct to the best of my knowledge and belief. I further affirm that I have not knowingly withheld any facts or circumstances in completing this application.
SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

JEAN B PURVIS COMMUNITY HEALTH CENTER OF BUTLER COUNTY

VOLUNTEER APPLICATION

STUDENT

EMPLOYED

Clearances

HIPPA/Confidentiality

Volunteer Agreement