HEARTSMART EKG AT HIGHLAND PARK HIGH SCHOOL IS CANCELLED ON APRIL 17, 2020.


Questions: Contact Kathy Aykroid, Kathy@HeartSmartEKG.org or 847-736-8140.
I would love to help! I have marked my calendar to attend training on: *
AND to volunteer for the following shift(s): *
Required
Name: *
Gender: *
Street Address: *
Mailing City: *
Cell phone number: *
Email: (All correspondence will be sent via email) *
Any special skills? EMT, RN, MD
CONFIDENTIALITY STATEMENT ~ MAX SCHEWITZ FOUNDATION SCREENS FOR TEENS CARDIAC SCREENING *
We assure the students and parents participating in the HeartSmart EKG protocol of their right to privacy of person and records according to the laws of confidentiality. We recognize that as providers of services and processors of medical patient records, we have a committment, an obligation, and a responsibility to protect their privacy of all information that we receive in the process. I understand that the performance of my volunteer work may directly, or indirectly, result in my gaining knowledge of confidential patient or organizational information. All medical, personal, or organization information, whether written, computerized, oral, or tangible in any other way is deemed confidential and will be treated as such. All users given access to information regarding participants in the HeartSmart EKG will keep confidential all information made available to them regarding medical, demographic, and organizational data. I have read the position on confidentiality and security of participant information and I understand any violation, whether intentional or unintentional, may result in my immediate removal from the program.
I grant permission to use any photographs, recordings or any other record of this event for any legitimate purpose of the Max Schewitz Foundation. We will ask your permission again just before we allow permit photos. *
Legal Name: *
Any additional information:
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy