Volunteer Information

At which clinic location are you wanting to volunteer? (Select all that apply)*

CrossEastbrookFlorist

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Email*

example@example.com

Birthdate*

mm/dd/year

Emergency Contact*

First NameLast Name

Emergency Contact Phone*

I am a:

Do you have a current license in the state of WI for:

What is your desired volunteer role? (select all that apply)*

Please list any additional languages you speak.

Days and Hours Available*

Education/Certification

How did you hear about the Bread of Healing Clinic?

Why do you wish to volunteer?

What experience do you have working or volunteering.

Please provide the name and number of two references:*

Statement of Confidential Compliance Information (HIPAA)

In the performance of your normal job duties, you have access to information that is confidential in nature. This information may include but is not limited to the following:

• Medical Data
• Billing Information
• Electronic Computerized Data

The laws of the State of Wisconsin require strict protection of the confidentiality of all patient information. Disclosure is permitted only under very specific circumstance and in most instances requires the written consent of the patient.

Your use and/or access to this type of information is required because of the nature of your job duties and assignments. You are required to protect this data and maintain the highest degree of confidentiality regarding its use, both within Bread of Healing Clinic and outside Bread of Healing Clinic.

Your use and/or access to all confidential material is to be limited to only the information required by your assignments. If you access information not required for your job, it will constitute misuse. Deliberate efforts to gain access to data you are not authorized for will constitute an abuse of your job responsibilities.

Any abuse, misuse, or dissemination of any confidential information (whether listed above or not) will result in disciplinary action, which can include termination of your volunteer contract.

Your signature indicates that you have reviewed this statement, read it, and understand your responsibilities.

I have reviewed the HIPAA statement and understand my responsibilities.*

Electronic Signature

Date*

mm/dd/year

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