HELPING HANDS HEALTH AND WELLNESS CENTER
VOLUNTEER INFORMATION FORM
Date: _____________________________
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
City: _____________________________________________ State: _______ Zip: ___________________
Phone: _____________________________________ Cell: ____________________________________
Email: _______________________________________________________________________________
What job(s) would you like to volunteer for?
___greeter
___community resources/social services
___admissions/discharges
___Providing meals or snacks for volunteers/patients
___nurse assessment
___prayer team
___physician assistant
___pharmacy
___physician
___other_____________________________
The clinic is open four times a month on two Fridays and two Thursdays, how often would you like to
volunteer?: ___________________________________________________________________________
Languages other than English you speak: ___________________________________________________
Could you interpret this language if asked? Yes No
What Medical License/certifications do you have, if any?: ______________________________________
Volunteers must provide a copy of all licenses and certifications to put on file.
Do you have CPR certification? Yes No
Date: ______________________________________________
Copy of certification will be needed to keep on file
Present Church: _______________________________________________________________________
References Name and Phone #:___________________________________________________________
Have you ever been convicted of a felony? : Yes No
Simple Background Checks may be done, do we have your approval: Yes No
Work Experience: ______________________________________________________________________
Volunteer Experience: __________________________________________________________________
Reason you would like to volunteer: _______________________________________________________
In case of an emergency, contact: name:___________________________ phone:__________________
Our doors will be open to many persons of diverse backgrounds, nationalities and
illnesses. Will you be comfortable with this? Yes No
Tuberculosis or Hepatitis B, are you currently experiencing either of these illnesses? Yes No Have
you been treated? Yes No
Have you been tested for TB in the last year Yes No
Have you had Hepatitis B shots Yes No
If no, please let us know when you are tested.
Signature: ____________________________________________ Date :__________________________
VOLUNTEER CONFIDENTIALITY STATEMENT
Due to the nature of information available through the Helping Hands Health and Wellness Center, it is
imperative that each staff member, whether paid or unpaid, understands and is committed to the issue
of confidentiality.
As a volunteer of the Helping Hands and Health and Wellness Center, I agree to respect and maintain
the confidentiality of all information, whether written or verbal, which pertains to the services provided
by the Helping Hands and Wellness Center and to make no voluntary disclosure of such information
except to persons authorized to obtain it. I will not discuss or distribute any information pertaining to
patient or staff information without the express written consent of the Executive Director or other
appropriate authority.
If I encounter a patient outside of the Clinic, I agree not to acknowledge the patient unless first
acknowledged by the patient. At no time will I acknowledge to anyone that I know the patient from the
clinic. Failure to comply with this policy may result in termination.
Signature of Volunteer_____________________________________ Date: ________________________
Print Name____________________________________________________________________________
RELEASE OF LIABILITY
I,_________________________, (insert volunteer’s name) hereby release and hold harmless the
Helping Hands Health and Wellness Center and its agents, employees, representatives, officers and
directors, from any and all liability, costs, damages, causes of action suits, and/or claims of any kind or
nature (collectively “claims”) related to or arising out of my providing volunteer services for Helping
Hands Health and Wellness Center.
This release applies to all claims, whether known or unknown, foreseen or unforeseen, that I have at any
time against Helping Hands Health and Wellness Center and its agents employees, representatives,
officers and directors.
As indicated by my signature below, I have read and fully understand the terms of this release. If I am
under 18 years of age, I have reviewed this release of liability which at least one of my
parents/guardians, and my parents/guardians have indicated acceptance of the terms of the release by
signing below and signing the Emergency Medical Authorization on the back of this release.
Signature of Volunteer: _______________________________________ Date: _____________________
IF VOLUNTEER IS UNDER 18 YEARS OF AGE
Signature of Parent/Guardian: __________________________________ Date: _____________________
Print Name: ___________________________________________________________________________
Relationship to Volunteer: _______________________________________________________________
Phone Number: ________________________________________________________________________
HBV VACCINE DECLINATION FOR VOLUNTEERS
“I understand that due to volunteering exposure to blood of other potentially infectious material, I may
be at risk of acquiring hepatitis B virus (HBV) infection. I decline going to obtain the hepatitis B
vaccination on my own at this time. I understand that by declining this vaccine, I continue to be at risk
of acquiring hepatitis B, a serious disease.
If, in the future, I continue to have occupational exposure to blood or other potentially infectious
materials and I want to be vaccinated with hepatitis B vaccine, I will seek receiving the vaccination series
through my private medical provider. I will then give proof of my vaccination series to Helping Hands
Health and Wellness Center.”
Signature: ____________________________________________________________________________
Print Name: ___________________________________________________________________________
Date: ________________________________________________________________________________