Thank you for volunteering at an upcoming Healing California Clinic. Your work will bring much needed care to underserved patients.

NEW PARTICIPANTS

1. Complete the form below. We do not sell or share your information with sources outside of Healing California.

2. If no Clinic events are open for registration, complete all information except the EVENT section to be added to the volunteer roster. You will be emailed when Clinic events are scheduled.

RETURNING PARTICIPANTS

1. Click the red button RECALL MY INFORMATION. Enter your username and password.

2. You will be taken to a dashboard where you can click to UPDATE your personal information, REGISTER for a specific event, EDIT an existing event registration, or CANCEL your event participation entirely.

3. The form will be repopulated with your information. Make updates, select when you want to participate and/or modify your selections, directly in the form.

If you have any problems or questions about the registration process, please email info@healingcaliforniacharity.org

PLEASE REMEMBER

Click SAVE AND SUBMIT at the end of the page to save your new or revised information.

 
      If you previously registered on this webpage, we will recall your information.
Do not RECALL your information and type over it for another family member. That overlays the existing record.
 
 
Abbreviated Title   Example: Mr., Ms., Dr., Hon., Mx.
 
     
Professional Abbreviations       Example: DDS, MD, PhD
Date of Birth       required
Name on Badge       List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam
 
 
  If possible, we would like to text you with occasional reminders and pertinent updates.
Mailing Address Line 1   Include apartment, suite or box number, if applicable.
Mailing Address Line 2  
 
 
 
  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.
 
        
  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. 
        
  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  < ' & * # .
 
       
Required Age
  I will be at least 18 years of age when I volunteer
  For legal reasons these are the age restrictions for volunteering.
 
T-Shirt Size   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 		  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.
         
Other Information
    Lifting     Are you able to lift over 25 lbs?
    Bloodborne Pathogen Training     Have you Received Blood-borne Pathogen training?
          
Company / Organization   Optional, but helpful to know especially if you're coming with an office or team.
Matching
My company has a matching program
  Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer.
Description   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.
 
First and Last Name  
Relationship    
Phone    
   
Event Area
  Select the event area appropriate to your profession / classification.
Profession / Classification
General Notes
(if needed)
 
License Number   Use this field to enter your license, registration or certification number, whatever type is relative to your profession.
Expiration Date    
Prof. Liability Insurance Carrier   Medical liability insurance is your responsibility.
State of Licensure   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   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.
     
Residency Location  
Residency Supervisor  
     

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.

School    
Field of Study / Degree Program    
Year of Study    
Onsite Faculty Supervisor    
       
 
Limit Event List by State?   Select a state to limit the list to only events in that state.
Event
  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.
 
Event Location
---
  More detailed directions will be available prior to your arrival.
Event Email
---
  Please add this information to your safe senders/callers list.
Event Phone
---
 
Event Information
 
 
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.     
Admin Code
For administrative or instructed use only.
Day Type Assignment
   
     
   
Select your profile picture   Specify profile explanation for registration page here
Your current picture
   
Specify explanation for uploading volunteer documents here
Document 1 Name      
Document 2 Name      
Document 3 Name      

No files have been uploaded
   
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.

Sign in the space below:
Please use your mouse to sign on a PC or use your mobile device touch screen
 
Thank you for registering as a volunteer. Upon clicking the SAVE AND SUBMIT button, you will be emailed a confirmation of your registration/updates.