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