Whitman-Walker Clinic, Inc

1701 14th Street, NW Washington, D.C. 20009 Tel. (202) 797-3510

APPLICATION FOR NON EMPLOYEE SERVICE

CONTACT INFORMATION

Full Name: First M. Last

Address: Number, Street, City, State and Zip

Telephone No.: (###) ###-####

Email Address:

SCHEDULE INFORMATION  FULL TIME (40hrs/wk)  PART TIME (Less than 32 hours)  On-Call  Summer Only

Schedule Limitations:

Date Available:

AREAS OF INTEREST

What WWH Programs Are You Interested In?

BACKGROUND INFORMATION

Have you previously volunteered with Whitman-Walker or  Yes  No participated in clinical training at Whitman-Walker? If yes, when?

Have you ever been convicted of a felony?  Yes  No

A conviction record will not necessarily be a bar to volunteering or If yes, please explain including date, place, conviction, serving as an unpaid intern. Factors such as the date of the offense, the disposition and any rehabilitation activities that took place: seriousness and nature of the offense, your history after the offense and rehabilitation will be taken into account. EDUCATION, TRAINING AND LICENSURE Certain volunteer activities may have education, training or license requirements. Please state all education and training you have received that you believe qualifies you for the volunteer position you are seeking. Education, training and license information would include a medical or legal degree, language skills, computer skills, accounting skills:

Whitman-Walker Health actively ensures and promotes equal opportunity in its recruitment of its volunteers. The health center does not discriminate against any applicant for voluntary services with regard to race, color, religion, sex, personal appearance, family responsibilities, matriculation, political affiliation, childbirth or related medical conditions, marital status, ancestry, sexual orientation, national origin, age, disability, genetics or status as a Vietnam-era or special disabled veteran, or any other status protected by applicable law. Discrimination or harassment based on being perceived as having an orientation for heterosexuality, bisexuality, homosexuality, or a gender identity different from that assigned at birth will not be tolerated. Our policy is to select the best qualified persons on the basis of skills, ability, experience, education, training, and/or other legitimate factors related to the requirements of the specific position for which the volunteer is being considered. No question on this application or in the volunteer selection process is intended to obtain information to be used for any discriminatory purpose. All information provided is confidential.

STATEMENT OF RESPONSIBILITIES FOR SERVICE

In conjunction with my Whitman-Walker Health Volunteer Application:

I, (full name) agree:

To fulfill my volunteer responsibilities as outlined in the position description of the program to which I am placed to the best of my ability;

To abide by all WWH policies and procedures, as detailed in Health Center materials provided to me and as conveyed to by WWH staff;

To attend any orientation or training sessions, and any team, supervisory or support meetings that are required of the position into which I am placed;

To provide considerate and respectful care for any client of WWH, without prejudice or discrimination of any kind and do so in a non-judgmental manner, without regard to sex, sexual orientation, gender identity or expression, race, religion, physical capabilities, educational level, political opinion or income;

To provide quality services as a WWH volunteer and to refer client requests for services that I am not specifically trained to provide to appropriate WWH staff as needed;

To be receptive to constructive suggestions and supervision from my supervisor;

To bring any problems that may arise in the course of my volunteer service to my supervisor for resolution.

Furthermore, I understand that:

The volunteer services that I provide WWH are to be rendered without any expectation of personal remuneration or gain of any kind, financial or otherwise; this agreement to serve as a volunteer in no way constitutes a contract of employment and that none of these documents, whether singly or combined, create an expressed or implied contract of employment for a definite period nor an expressed or implied contract concerning any terms or conditions of employment;

I am not expected to direct the decisions, medical or otherwise, of any client of WWH, nor those of the client's family or significant others and will respect the client's right to refuse or terminate WWH services at any time; I must abide by all Federal and State safety laws and regulations applicable to WWH and its staff including but not limited to safety rules and regulations and OSHA guidelines for safety and blood borne pathogens posted at the Health Center and my volunteer work is solely at the discretion of WWH and that my status as a volunteer may be terminated by WWH at any time.

As a volunteer at WWH who will not be engaged in providing direct health care services to WWH clients, I will not have access to electronic medical records or Protected Health Information involving clients of the health center. If I should learn the identity of any WWH client during my volunteer service, I agree not to disclose that or any other potentially sensitive information to any individual or entity outside of WWH. I also agree not to disclose any potentially sensitive or non-public information about Whitman-Walker Health that I may acquire during my volunteer service to any individual or entity outside of WWH.

Signed: ______Dated: ______

Release & Authorization to Conduct Background Investigation FOR NON-EMPLOYEES: CONTRACTORS, INTERNS, EXTERNS, FELLOWS, VOLUNTEERS, OTHER Whitman-Walker Health (WWH) may require prospective or current non-employees (independent contractors, interns, externs, fellows, volunteers or other non-employees seeking to provide services) to submit to background checks as a condition of entering into the affiliation or relationship. This is necessary for WWH to ensure that it engages with honest and trustworthy individuals and to protect the property and safety of WWH, its employees, patrons and visitors. I hereby authorize WWH, either directly or through an outside service provider, to perform all checks of my credentials as allowed by law, including but not limited to: credit, identity, criminal, driving record, school records, educational credentials, employment verification, and references. I hereby authorize without reservation any party or agency contacted by WWH or its agents to furnish the above-mentioned information, and that a photocopy of this authorization be accepted with the same authority as the original. I agree not to assert any claims or causes of action of any kind against WWH, its agents and/or its employees, arising out of WWH’s investigation. I further release and forever discharge WWH, its agents and/or its employees, and the individuals and companies contacted by WWH as part of the investigation, from any and all claims, demands, damages, actions, causes of action, or suits of any kind arising from WWH’s investigation of my background and credentials as they relate to my suitability. I acknowledge my right to make a request of the provider of these reports, upon proper identification and the payment of any authorized fees, for a copy of the reports in its files on me at the time of my request, and to receive from them a statement of my rights under the Fair Credit Reporting Act, 15 U.S.C. § 1681, et seq. The following information is used for Search Report Identification Purposes Only. Your Full Name Here:

Social Security Number: Date of Birth: MONTH Select DAY YEAR Current Address: (Number, Street Name, Apt. / Unit No., City, State, Zip Code)

Length of Time at Current Address: YEARS MONTHS If less than 7 years at current address, please complete with the previous address: Previous Address: (Number, Street Name, Apt. / Unit No., City, State, Zip Code)

Length of Time at Previous Address: YEARS MONTHS Driver's License #: Issuing State:

Today’s Date:

My Signature (in the box): E M E R G E N C Y C O N T A C T F O R M

This information will be used only in case of an emergency and will not be released for any purpose other than that listed above. Disclosure is voluntary. Failure to provide the requested information may result in an inability to locate a family member in the event of an emergency.

Service Member Name (Please Print): Service Member’s Home Phone #:

Date: Service Member’s Cell Phone #:

Name of 2 emergency contacts:

Contact Name: Contact Name:

Relationship: Relationships:

Daytime Phone #: Daytime Phone #:

Evening Phone #: Evening Phone #: