Volunteer Form

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Full Name*

Phone*

Email*

Highest Level of Education*

How would you like to volunteer?*

Administrative
Clinical
Patient Access
Communications
Finance
Quality and Data Reporting
Operations
Other (place in comments)

How did you hear about us?*

Social Media
Website
Online or Internet Search
Word of Mouth
Other (place in comments)

Can you speak other languages besides English?*

Comments

Consent*

I agree to the volunteer and confidentiality policy.

Volunteer Policy
• I understand that I am responsible for becoming familiar with the disaster and communicable disease policies and procedures at HJAHC.
• I understand that if I am absent, I agree to notify my manager as early as possible. I understand that 3 no-show/no-calls may result in dismissal from my duties at HJAHC.
• In order to receive a letter of recommendation, I must commit to a consistent period of time contingent upon my satisfactory performance and evaluation.

Confidentiality Policy
HJA has a confidentiality policy for all persons representing or providing services for HJAHC. More stringent rules apply to the Medical and Dental Clinic (Refer to HIPAA). This includes Board Members, Medical and Dental Staff, all facility personnel, independent contractors, and all volunteers. Breach of this policy can mean termination of positions, services, employment, and/or other contracts.

All facility information must remain within the facility. This includes but is not limited to: any patient-related information, personnel records, meeting activities, and minutes, quality improvement activities, financial information, risk management issues and computer/security codes or information concerning any peer review activities.

It is required that this policy be a part of orientation for all new persons, including Board Members, Dental and Medical Staff and Volunteers. Implementation of this policy is the responsibility of all Department Managers, Physicians, Dentists, Directors, Meeting Chairpersons and individuals providing services in this facility.
Dress Code Policy
Volunteers and staff are part of HJAHC public relations and presenting a good image of HJAHC is one of our goals. In an effort to maintain a professional and safe environment for our volunteers and staff, HJAHC has adapted a dress code policy, as part of the Employee Handbook.
• Clothing: clean, casual, well groomed. (No bare midriffs. No short skirts, dresses, or shorts. No torn clothing, hats, or tank tops, no risqué prints on clothing.)
• Clinic volunteers are required to wear blue scrubs and/or lab coat and must comply with OSHA
guidelines.
• Shoes: sturdy, non-skid closed toed shoes are required. No flip flops or very high heels…Be safe!
• No excessive jewelry, makeup, or perfume/aftershave (some may be allergic).

Volunteer Acknowledgement
• I understand that all instruments, equipment, materials, supplies, clothing, and food donated to HJAHC
or purchased by HJAHC are property of HJAHC and may not be removed without permission.
• I understand that failure to comply with this policy may result in disciplinary action, which could include termination.

All information submitted by me in this application is true to the best of my knowledge and belief. I understand that I will be serving HJAHC clients and patients on a volunteer basis and will not be remunerated for services rendered.
I understand the above contract and agree to comply with all HJAHC policies and regulations.

Verification

Volunteer

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