By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

It is the policy of Free Clinic of Powhatan to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

This Confidentiality Agreement ("Agreement") is made and entered into this {day} day of {month}, 20{year}, by and between THE FREE CLINIC OF POWHATAN, INC. and {fullName} (“ Employee/Volunteer”).This agreement will be signed annually.

RECITALS

1. WHEREAS, The Free Clinic of Powhatan, Inc. is a Virginia Corporation organized exclusively for charitable purposes.
   
   
2. WHEREAS, The Free Clinic of Powhatan, Inc. desires to employ the Employee or utilize the services of the Volunteer.
   
   
3. WHEREAS, The Free Clinic of Powhatan Inc. expects Employee/Volunteer to provide medical and other related services associated with providing care to the patients of The Free Clinic of Powhatan.
   
   
4. WHEREAS, Employee/Volunteer will have access to, and will need to have access to, Confidential Information to perform Employee’s/Volunteer’s duties.
   
   
5. WHEREAS, The Free Clinic of Powhatan, Inc. are the owners and users of confidential information and desire to protect such Confidential Information from unauthorized disclosure or appropriation.
   
   
6. WHEREAS, Employee/Volunteer acknowledges such protection of Confidential Information is reasonable and necessary to protect the legitimate interests of the Free Clinic of Powhatan, Inc.

NOW THEREFORE, in consideration of the premises stated above, the mutual promises contained in this Agreement and Free Clinic’s employment of Employee/Volunteer, it is agreed as follows:

1. ACCESS TO CONFIDENTIAL INFORMATION.  During the course of employment or volunteering, Employee/Volunteer will have access to certain personal and valuable information of the patients of The Free Clinic of Powhatan. Such information includes, but is not limited to, medical and dental conditions and history, prescriptions, employment and financial data and other similar personal information. (Such information collectively is the "Confidential Information").
   
   The Free Clinic of Powhatan, Inc. agrees to provide Employee/Volunteer with access to all such Confidential Information as The Free Clinic of Powhatan deems shall be necessary from time to time in order for Employee/Volunteer to effectuate properly the duties of employment/volunteering at such time.
   
   
2. PROTECTION OF CONFIDENTIAL INFORMATION.  Employee/Volunteer acknowledges and agrees that all of the Confidential Information is strictly confidential. No reference shall be made inside or outside the clinic about a patient’s identity, diagnosis, treatment, or other confidential information about the patient.  This includes verifying if a person has been seen at the clinic and giving information to the parent of a child 18 years and over.