Volunteer Application

VOLUNTEER EXPERIENCE

YOUR AVAILABILITY 

REFERENCES

VOLUNTEER AGREEMENT AND CERTIFICATION OF INFORMATION

In knowledge that The Children’s Clinic, “Serving Children and Their Families” DBA TCC Family Health (TCC) has need of my services as a volunteer, I agree: To hold as absolutely confidential, in compliance with HIPAA regulations, all information which I may obtain directly or indirectly concerning patients, parents, doctors, or TCC personnel, and will not seek confidential information in regards to a patient.
That my services are donated to TCC without contemplation of compensation, or future employment and given with humanitarian or charitable reasons.

My signature below certifies that all statements made on this application are true, complete and correct to the best of my knowledge. I understand these statements are subjection to verification and that falsification on this application can disqualify me from consideration or result in my volunteer services being denied. I release TCC Family Health (TCC) and my former employers and all others from any liability from damage that may result from such an investigation, if, upon investigation, anything contained in this application is found to be untrue. I further agree to conform to the rules and regulations of this facility. I understand that my volunteer status at TCC can be terminated at any time for failure to comply with the policies, rules, and regulations of the organization; for absences without notification; for reasons of unsatisfactory attitude, work or appearance; and for any other circumstances which, in the judgment of TCC, would make my continued service as a volunteer contrary to the best interests of TCC. Furthermore, my signature below provides my authorization to TCC to conduct reference checks to determine my suitability for placement.

The Children’s Clinic, “Serving Children and Their Families” DBA TCC Family Health acknowledges that equal opportunity for all persons is a fundamental human value. Each volunteer applicant will be considered on the basis of individual ability and merit, without regard to race, color, age, religion, national origin, disability, sexual orientation, sex, or marital status.

If you are under the age of 18, please continue filling out this application by clicking the 'Next' button. For those that are 18 and over, you may now submit the volunteer application. 

PARENTAL CONSENT (to be completed if applicant is under the age of 18)

My son/daughter has my permission to serve as a Teen Volunteer with The Children’s Clinic, Serving Children & Their Families DBA TCC Family Health (TCC). As the parent/guardian of the above-named student, I will read the literature that is provided to my child so that I know what is expected of him/her.

I attest that my child is at least 16 years of age and is free from communicable diseases and will be able to provide evidence of negative TB screening and proof of immunization (signed by licensed nurse or healthcare provider who is not the child’s relative), immunity by laboratory results, or natural disease history, or rubella (German measles), rubeola (measles), and varicella (chicken pox).

I do hereby release TCC, their staff and sponsors from any responsibilities of injury or accident as a result of the volunteering experience. Any medical expenses incurred as a result of injury or accident will be my responsibility.

I understand that in case of a medical emergency, every attempt will be made to contact me before medical action is taken. However, this document is my consent as a parent or guardian for emergency treatment and/or procedures necessary for my son/daughter by the professional staff at The Children’s Clinic, Serving Children & Their Families DBA TCC Family Health (TCC).