Volunteer Sign-Up for Community Flu Immunization Clinic Carson City Drive-thru Clinic

Volunteer Sign-Up for Community Flu Immunization Clinic
REVISED: Douglas County Drive-thru ClinicNovember 8, 2014
Carson City Drive-thru ClinicOctober 24, 2014
Name: _______________________________________________
Date: __________________________
PLEASE PRINT CLEARLY
I have volunteered for a clinic before:
 Yes
 No
I am a member of the following organization(s)
 CERT
 MRC (Medical Reserve Corps)
 Other _____________________________
I am volunteering for:
 Drive-thru Clinic: Carson City Corporate Yard Friday, October 24, 2 pm6 pm
 Drive-thru Clinic: Douglas CountyGE Bently Parking Lot Saturday, November 8, 9 am1 pm
I am a Medical Volunteer:







License Number
Expiration Date I prefer to be assigned to:
RN
_____________
_____________
LPN
_____________
_____________
Medical Assistant
_____________
_____________
Physician
_____________
_____________
EMT
Pharmacist
Other ___________
_____________
_____________
_____________
_____________
_____________
_____________
 Medical Screening
 Vaccinator
 Supplies/Vaccine Management
 Exit Reviewer
 Floater – Answering medical
questions from the public
I am a Non-Medical Volunteer: I prefer to be assigned to: (check all that apply)
 Greeting the public
 Forms/Registration
 Traffic Flow
 Conducting Exit Survey
 Floater/Runner
 No Preference
If you have the following restrictions, please DO NOT volunteer for these clinics, as you will be
standing outdoors for up to 6 hours.
Cannot stand for long periods
OR
Cannot be outdoors
I speak another language(s) besides English:
 Yes  No
Please list: __________________________________________________________________________
 Male  Female
 65-74 yrs  75 yrs or older
Please verify your demographic information for our records:
Age:  16-24 yrs
 25-49 yrs  50-64 yrs
(Must be at least 16 years old to participate)
Home Address:
_________________________________________________________________________________
Street Address
City/State/Zip Code
Home Phone: _______________ Work Phone: _______________ Cell Phone: ________________
E-mail address: _________________________________________  Home
 Work
Mail or Fax to: Carson City Health & Human Services • 900 E Long St • Carson City, NV 89706
Attn: Taylor Radtke • Fax (775) 887-2248 • Phone (775) 283-7908
Douglas County Volunteers ONLY who are NOT CERT or MRC Members, or not
employees of Douglas County or Carson City Must Complete this Form
Personal References:
1.____________________________________________________________________________________
(name)
(address)
(phone)
(relationship)
2.___________________________________________________________________________________
(name)
(address)
(phone)
(relationship)
3.___________________________________________________________________________________
(name)
(address)
(phone)
(relationship)
Have you ever been convicted of a crime (other than a minor traffic violation)?  Yes  No
If yes, state date, location and nature of the offence:____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I am referring a friend/relative who would like to volunteer! (Optional)
Name:__________________________________ Email:_________________________________________
Home Phone:____________________________ Work Phone:___________________________________
Address:______________________________________________________________________________
PERMISSION AND RELEASE
I agree to participate in any training and activities as requested.
I understand that I will be given an opportunity for training and will follow the instruction I am given and all
applicable County policies and procedures.
I also understand that I will be covered under the Douglas County workers compensation coverage while
performing my volunteer activities. I understand that I am responsible for following any and all associated
requirements, including reporting any injury in a timely manner and completing all necessary forms.
I know of no health or fitness restriction(s) that precludes my participation in volunteering. In the event of
illness or injury occurring to me while involved with any such activity, I consent to necessary medical
treatment, including treatment that is considered necessary in the best judgment of the attending physician
and performed by or under the supervision of a member of the medical staff of the medical facility furnishing
medical services.
I acknowledge that Douglas County will conduct a criminal / driving background. By signing this form, I
acknowledge and agree to this background check.
By signing this form, I release Douglas County from any and all liabilities incurred in these activities.
To my knowledge the above information is true.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (as amended) limits disclosure of
the protected health information of any patient to specific uses such as the provision of treatment or other
health care services, for billing and payment purposes, and for health care operational purposes. As a
participant in the Flu Shot Clinic, you are specifically prohibited from discussing individual patients, their
treatment and any other information that could be utilized to identify these patients with anyone expect those
personnel you are working with at the Clinic. Any disclosure of patient information may subject you to civil
and/or criminal penalties, as prescribed by law.
_______________________________________
Print Name
_______________________________________
If Minor at least 16 years of age, Parent/Guardian Name
_______________________________________
Signature
_______________________________________
Parent/Guardian Signature