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SEAGER MEMORIAL CLINIC NEW VOLUNTEER FORM
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First and Last name *
Phone number *
Email address *
Complete mailing address *
Will you please send a photo of yourself to our clinic manager within two weeks to display on our volunteer recognition board? *
Required
Position you're interested in volunteering.  *
Required
PROVIDERS ONLY: NPI number.

PROVIDERS and RNs ONLY: License number.

MEDICAL PROVIDERS ONLY: Check the type of care you're NOT comfortable treating.
PHYSICIANS ASSISTANTS ONLY: How many PA clinical hours do you have? 

Spanish speaking?  *
Required
Days you’re available - check all that apply:   *
Do we have your permission to do a background check?  *
Required
Have you completed any HIPAA compliance training?  *
Required
How often a month are you able to volunteer?  *
Where did you hear about Seager Clinic? *
Are you a WSU student or OTECH student COMING WITH FACULTY or a Weber-Morgan Medical Reserve Corps (WMMRC) volunteer?  *
Required
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. Our clinic manager will provide you a copy upon request.  *
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