Volunteer Application - FISH MD Medical

FISH MD Volunteer Application

Thank you for applying to serve at FISH!
Thank you for your willingness to serve as a volunteer with FISH!
It's people like you who make the Ministry of
Faith in Serving Humanity possible.
FISH Volunteer - Individual
Full Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Best Phone #

Area CodePhone Number
Birthdate

MonthDayYear
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number

Please tell us about your medical experience.

Other
Please list any medical certifications or licenses that you hold
Please share your professional medical experience, for example working as a nurse or doctor in a hospital, experience in medical office, working as a health educator with patients...
What other special gifts, skills, or experience do you have that you could use while volunteering at a FISH MD medical clinic? (Strong communication skills, organizational skills, medical office, clerical experience, medical records, etc.)
Do you have any physical limitations that we should be aware of?
List physical limitations.
Do you have any special circumstances or comments about volunteering with FISH?

CONFIDENTIALITY & NON-DISCLOSURE AGREEMENT

I acknowledge that in connection with my duties as a staff member or a volunteer for Faith In Serving Humanity (F.I.S.H.), FISH-MD or FISH 4 KIDS, I may gain access to the demographic information, and personal health information, (as defined herein) of patients/clients to be serviced through the clinic, or families in need of assistance through the ministry, which is required by law to be kept confidential. For and in consideration of my participation in the ministry and/or clinic, I agree as follows:
1. Demographic Information refers to information that identifies an individual (name, address, telephone number, etc.).
2. Personal Health Information relates to past, present or future physical or mental health conditions, or any other information disclosed by a patient/client or discussed with a patient/client regarding the provision of services provided through the ministry and/or clinic
I understand that the ministry and/or clinic’s leadership expects me to hold in confidence and not disclose, directly or indirectly, any personal information, or any portion thereof, communicated, discussed, delivered, or made available by any patient/client. I acknowledge that my obligation under this Agreement remains in effect indefinitely. I will take reasonable precautions to ensure that the confidentiality of each patient’s/client's personal information is maintained and will follow all ministry and/or clinic procedures in that regard. The ministry’s and/or clinic’s policy is to safeguard access to personal information by taking reasonable steps to maintain its security. I will not discuss personal information in public places or outside of the ministry buildings or clinics. As a representative of FISH, FISH-MD, and FISH 4 KIDS, I acknowledge that I may disclose personal information only to volunteers or to authorized advisors and consultants of the ministry and clinic who have a specific need to know such information in order to serve the patient/client.

I also understand that the Health Insurance Portability and Accountability Act (HIPAA), as established by the Department of Health and Human Services, requires that all clinic personnel maintain the privacy of all patient health information obtained in confidence. The HIPAA law, passed in 1996, provides every patient with the right to privacy regarding their health information.
By typing your name below and clicking "Submit," you acknowledge that you have read, understood, and agree to the Faith in Serving Humanity Confidentiality and Non-Disclosure Agreement. You agree that your typed name constitutes your electronic signature and is the equivalent of your handwritten signature.
Type your name here...
Date

MonthDayYear
Date

FAITH IN SERVING HUMANITY
CODE OF CONDUCT FOR STAFF AND VOLUNTEERS

The mission statement of FISH:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, F.I.S.H endeavors to respond to the Spiritual, physical, and financial needs of Walton County residents.

The mission statement of FISH4Kids:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, FISH4Kids endeavors to provide each at-risk child of Walton County an opportunity to succeed.

The mission statement of FISH MD:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, F.I.S.H. MD endeavors to respond to the Spiritual and health needs of Walton County residents.

Ephesians 4:32
Be kind to one another, tenderhearted, forgiving one another, as God in Christ forgave you.

Ephesians 4:1-6
I, therefore, a prisoner for the Lord, urge you to walk in a manner worthy of the calling to which you have been called, with all humility and gentleness, with patience, bearing with one another in love, eager to maintain the unity of the Spirit in the bond of peace. There is one body and one Spirit-just as you were called to the one hope that belongs to your call- one Lord, one faith, one baptism, one God and Father of all, who is over all and through all and in all.

Philippians 4:8-9
Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is commendable, if there is any excellence, if there is anything worthy of praise, think about these things. What you have learned and received and heard and seen in me-practice these things, and the God of peace will be with you.

I do hereby understand that in my service at FISH, FISH4Kids, FISH Medical, and Dental, I represent Christ. I will conduct myself in a manner that promotes a positive and joyful attitude. I will pray for FISH, FISH4kids, and FISH Medical and Dental.

I believe and support the mission statements of FISH, FISH4Kids, and FISH Medical and Dental:
By typing your name below and clicking "Submit," you acknowledge that you have read, understood, and agree to the Faith in Serving Humanity Confidentiality and Non-Disclosure Agreement. You agree that your typed name constitutes your electronic signature and is the equivalent of your handwritten signature.
Type your name here...
Date

MonthDayYear
Date
Please verify that you are human
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FISH MD Volunteer Application