Clinic Volunteer Registration |
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Contact Information
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Abbreviated Title |
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Example: Mr., Ms., Dr., Hon., Mx. |
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Professional Abbreviations |
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Example: DDS, MD, PhD |
Date of Birth |
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required |
Name on Badge |
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List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam |
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If possible, we would like to text you with occasional reminders and pertinent updates. |
Mailing Address Line 1 |
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Include apartment, suite or box number, if applicable. |
Mailing Address Line 2 |
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We recommend an email address unique to the registered volunteer instead of a shared office address or the personal address of a group leader for all group members. We will send personalized scheduling correspondence to this address. |
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Establish your unique User Name. You may use your email address as your User Name unless another registered volunteer will be receiving correspondence at that same address. |
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Used to recall your information when you visit this site again so you can make changes and/or select additional volunteer opportunities. Your password must be at least 8 characters and contain at least one letter and one number. It may not contain the characters < ' & * # . |
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Required Age |
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For legal reasons these are the age restrictions for volunteering. |
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Demographics and Background
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T-Shirt Size |
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T-Shirt style is adult unisex. Note that t-shirts may not be provided at all events. |
Language Fluency (other than English)
Select all that apply
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Hold down the control key to select more than one language.
Hold down the control key and click on a selected language to de-select it. |
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Other Information |
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Company / Organization |
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Optional, but helpful to know especially if you're coming with an office or team. |
Matching |
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Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer. |
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Description |
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Describe the program requirements and let us know how we can help - provide information for anyone we must contact and/or list any documentation you might need etc. |
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Emergency Contact
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First and Last Name |
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Relationship |
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Phone |
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Profession or Volunteer Classification
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Event Area |
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Select the event area appropriate to your profession / classification. |
Profession / Classification |
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License Number |
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Use this field to enter your license, registration or certification number, whatever type is relative to your profession.
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Expiration Date |
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Prof. Liability Insurance Carrier |
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Medical liability insurance is your responsibility. |
State of Licensure |
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Only U.S. licensed professionals can volunteer as medical providers. Out-of-state providers MUST submit a Dept. of Health attestation form to volunteer. |
License Comment |
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List additional information we should know. Examples: You selected Other Professional - indicate field/specialty. Your license will renew before the clinic. You are licensed in a second field - provide license details. |
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Residency Location |
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Residency Supervisor |
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We welcome student participation, however student spaces are limited and students may be restricted in their type of involvement in direct patient care. The criteria for student participation also varies by discipline.
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School |
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Field of Study / Degree Program |
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Year of Study |
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Onsite Faculty Supervisor |
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Limit Event List by State? |
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Select a state to limit the list to only events in that state. |
Event |
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To sign up for multiple events, complete your entire registration and assignment selections for the first event and click SAVE AND SUBMIT. Then come back to choose a second event and make assignment selections. Again, click SAVE AND SUBMIT to ensure its complete. |
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Event Location |
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More detailed directions will be available prior to your arrival. |
Event Email |
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Please add this information to your safe senders/callers list. |
Event Phone |
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Event Information |
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For each date select an assignment or "Not Attending This Day." If your preferred assignment is full, a waiting list option may be shown. If you choose to be on the waiting list for your preferred assignment (i.e. Computer Support) you will be given the option to select an alternate assignment (i.e. General Support). If an opening becomes available in your preferred assignment and you are moved from the waiting list, you will receive an email notice of this change. If you also selected an alternate assignment, you will be automatically canceled from the alternate assignment.
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Assignment Specific Questions (If Any)
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Optional Profile Picture
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Select your profile picture |
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Specify profile explanation for registration page here |
Your current picture |
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Upload Volunteer Documents (if needed for your assignments)
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Specify explanation for uploading volunteer documents here
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No files have been uploaded
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Volunteer Agreement
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Thank you for volunteering at our event. Each volunteer is required to read and sign this Volunteer Agreement and Liability Waiver as a condition of participating in the event. By signing below, I, the undersigned volunteer, agree to provide services to as a volunteer. As a condition of volunteering, I agree as follows: 1. I am donating my services and I am not entitled to any present or future salary, wages, or other benefits. 2. I knowingly assume the risk of participating as a volunteer. In consideration of participating as a volunteer, I, for myself, my spouse, my legal representatives, heirs, and assigns, hereby forever unconditionally waive all claims (in law, equity, or otherwise) against this organization, and their respective subsidiaries, affiliates, partners, officers, trustees, officials, employees, and agents, and volunteers, arising out of my participation in the these events. 3. In compliance with the federal and state privacy laws, I agree to hold in confidence all personal and protected health information I may overhear or come in contact with during and following the performance of my volunteer duties. I further agree not to access, or remove from the premises, personal and protected health information or records unless relating to my performance of my assigned duties. It is understood that I shall be responsible for any direct or consequential damages resulting from my violation of this requirement. 4. I also grant this organization and their respective agents the right to use, without payment or consideration of any kind, my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing these events and activities in all forms of media in perpetuity. 5. I agree to notify event officials immediately if I am injured or if I become aware of any accident or injury to another volunteer or clinic participant. 6. I understand that this organization's officials maintain the right to revoke my participation at any time with or without cause. By signing below I am indicating that I have read this agreement and fully understand its terms and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me, and intend my signature to be a complete and unconditional release of all liability.
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Sign in the space below: |
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Please use your mouse to sign on a PC or use your mobile device touch screen
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Save and Submit - To Generate Confirmation
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Thank you for registering as a volunteer.
Upon clicking the SAVE AND SUBMIT button, you will be emailed a confirmation of your registration/updates.
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