SEAGER MEMORIAL CLINIC NEW VOLUNTEER FORM

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Email *

First and Last name *

Position you're interested in volunteering. *

Spanish Interpreter

MA or Patient Tech. (Must be able to take vitals) We are currently full, but will reach out when we have openings.

Pharmacy Technician Student at OTECH

Front Desk (We are currently full, but will reach out when we have openings.)

Dental Assistant

Specialty Events i.e. Health Screening Day, Yard Sale, Charity Recital, etc.

Pharmacy Technician- CPhT (We are currently full, but will reach out when we have openings.)

Medical Provider - Physician

Grant Writer

Pharmacist

Phone number *

Mailing address *

Email address *

Days you’re available- check all that apply: *

Monday 3 - 6 PM OR 2:30 - 6 PM for MA's, RNs, Front Desk

Wednesday 3 - 6 PM OR 2:30 - 6 PM for MA's, RNs, Front Desk

Thursday - ADULT EYE CLINIC only

Friday 3 - 6 PM OR 2:30 - 6 PM for MA's, RNs, Front Desk

N/A I'm an event volunteer (i.e. Health Screening Day, Yard Sale, Charity Recital, etc.)

Required

Are you able to draw blood? *

Yes, I’m very comfortable drawing blood

I’ve been taught but it’s been a while, would need a refresher

N/A

Will you please send a photo of yourself to April within two weeks to display on our volunteer recognition board? *

Yes

N/A I'm an event volunteer (i.e. Health Screening Day, Yard Sale, Charity Recital, etc.)

Spanish speaking? *

Yes well enough to interpret

A little

Do we have your permission to do a background check? *

YES

N/A I'm an event volunteer (i.e. Health Screening Day, Yard Sale, Charity Recital, etc.)

Have you completed any HIPAA compliance training? *

YES

Required

Medical or dental license number and expiration date OR put N/A if your position doesn't require one. i.e., MA, Translator or Front Desk *

Emergency contact name and phone number *

How often a month are you hoping to volunteer and for about how long? N/A for event volunteers *

Where did you hear about Seager Clinic? *

SEAGER MEMORIAL PRIVACY POLICY CONFIDENTIAL AGREEMENT: Confidential information is defined as any information found in a patient’s medical record, or identifying personal information. All information relating to a patient’s care, treatment, or condition constitutes confidential information.Volunteers shall never discuss a patient’s medical condition with any non-affiliate of the Clinic, including friends or family members. Confidential matters involving patients should not be discussed in areas where they might be overheard by other patients or other non-affiliates of the Clinic. Volunteers are to be aware at all times that conversations regarding patients are not to be overheard by others and take appropriate steps to ensure this confidentiality. Confidential information should never be shared on social media even with patient identifiers removed. Any confidential information taken from one site to another must be protected: hard copy information in a locked car/case and out of sight, or constantly supervised; or password-protected document (if electronic copy). Any unauthorized disclosure of confidential information by volunteers will render the volunteer subject to disciplinary action up to and including termination from any further volunteering opportunities and prosecution under the law. I have received a copy of, read, understand, and agree to uphold this policy. I also understand that in my volunteer duties, I will have access to confidential patient information and that any violation of confidentiality could result in disciplinary action up to and including termination and/or legal action. I recognize that this electronically signed document will be kept on file. TYPE YOUR FULL NAME BELOW. *

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