VOLUNTEER APPLICATION 1 - About Volunteering | 2 - About You | 3 - Title 39 and Code of Conduct Signatures Step 1 of 3 33% ABOUT VOLUNTEERINGGive Your Heart As You Give Your Time! You can be the safety net for those outside of Medicaid eligibility and who require healthcare help and support. Your Area(s) of Interest* Dental & Medical Mental Health Community Health Other Needs Please select as many of the options above. as applicable.Dental & Medical* Dentist Dental Hygenist Dental Assistant Clinical Provider (MD, DO, NP, PA) Nurse (RN, LPN) Medication Assistance Program (MAP) Navigator Pharmacist Clinic Pharmacy Tech Other Please select as many of the options above. as applicable.Mental Health* Counselor Counselling Intern Other Please select as many of the options above. as applicable.Community Health* Licensed Clinical Social Worker Case Manager Community Resources Navigator (Community Health Worker) Patient Education Other Please select as many of the options above. as applicable.Other Needs* Receptionist Spanish Translator Patient Intake/Eligibility Genesis Community Representative Salesforce Support Research/Data Analysis Data Entry Web Design Christian Prayer and Spiritual Support Grounds Maintenance/Landscaping Facilities Repair/Maintenance Other Please select as many of the options above. as applicable.If other, please enter interest here:* ABOUT YOUName* First Middle Last Suffix Contact Phone*Work Phone #Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Occupation Professional License(s)Max. file size: 512 MB.Please attach current copy of professional license if this is applicable to the volunteer position you are seeking.Relevant ExperienceGOALS AND MOTIVATIONThe following questions will help us understand your goals and motivation for volunteering, and the time you have available. Are you affiliated with a local church? YES NO If yes, church name* What are your personal objectives/motivation for volunteering with Genesis?* Would volunteering with Genesis fulfill a job or school requirement, or a required community service such as St. Luke’s Professional Ladder Program? Yes No Program Name/Description What is the minimum period you plan to volunteer? (e.g. 3 months, 1 year, etc.)* How many hours per month do you hope to volunteer?* Please indicate your preferred Genesis clinic location:* Garden City Caldwell Both Would you like to subscribe to our email newsletter?* YES NO Email addresses are not shared or sold, and are subject to the Genesis Community Health Privacy Policy and Use Guidelines.How Did You Hear About Genesis? (Check All That Apply) Friend or Relative Colleague Event Social Media Radio Internet Search Genesis Letter Genesis Postcard The next page contains signature sections. Title 39 Liability*Title 39 Health and Safety Chapter 77 Volunteer Health Care Provider Immunity From Liability for Health Care Providers Providing Charitable Medical Care. “Any Health care provider who voluntarily provides needed medical or health care services to any person at a free medical clinic without compensation…shall be immune from liability for any civil action arising out of…such…service.” I understand that I am immune from liability if I provide service without compensation as per the title and chapter above. Title 39 Liability Acceptance and Signature*Type you full name as confirmation that all information entered is accurate and that it is your intent to submit this application to Genesis Community Health Genesis Community Health Volunteer Code of Conduct and Confidentiality AgreementPlease read through the statement below and type your name as confirmation of your agreement to it. Genesis Community Health is a non-denominational Christian organization working to convey the love of Jesus Christ by meeting the physical, medical, and spiritual needs of the less fortunate, both globally and locally. As a Volunteer of Genesis Community Health in any of its projects, I understand the stated mission of the organization. With that mission in mind, I affirm I will conduct myself in accordance with the following standards. I agree to serve as a volunteer and commit to the following: To perform my volunteer duties to the best of my ability To adhere to the policies and procedures, including record keeping requirements, client confidentiality and agreed upon medical scope of practice. To meet time and duty commitments, or to provide adequate notice so that alternate arrangements can be made. I agree to treat each patient as the most important patient in my care, attending promptly to his or her needs and concerns; acting always in his or her best interest. I agree to be attentive, patient and kind; understanding that patients and families are in a stressful situation and an unfamiliar environment. I agree to greet patients, families, visitors and co-workers with a warm welcome and genuine smile. I agree to invite service comments and concerns, responding immediately to customer dissatisfaction with a sincere apology and offer to remedy the situation. I agree to honor the intent of donated materials and follow established protocol in all areas, including those regarding my own personal needs. I agree to conduct myself in a manner consistent with the vision of Genesis Community Health. I agree in perpetuity to allow Genesis Community Health to use my likeness in a photograph in any and all of its publications, including website entries, without payment or any other consideration. I agree that as a volunteer I will come to know confidential information found in a medical setting. I will not disclose or discuss such privileged information to anyone. I will not reveal names of patients, nor visit a patient I know unless that information has come to me outside of clinic records. Any specific patient and physician medical information will not be discussed in any public area of the clinic, or outside of the clinic. I agree that if I am performing any volunteer function that requires a medical license in the State of Idaho, that I am currently licensed and that my license has neither been revoked nor suspended. I promise that should it become suspended, revoked or lapsed that I will notify Genesis Community Health within 30 days and will not be able to volunteer for those responsibilities anymore. I authorize GCH to email me and send me regular mailings from which I can later request to be removed from. The manner in which Genesis Community Health strives to treat all individuals is with dignity, respect and empathy, placing the needs of those we serve above our own, regardless of our judgment of their worthiness to receive it. I understand that any breach of confidentiality will result in the termination of my volunteer position. *Type your full name to confirm that you've read and agree to the Volunteer Code of Conduct and Confidentiality Agreement.Code of Conduct Acceptance and Signature*Type you full name as confirmation that you have read and agree to the Code of Conduct and Volunteer Application for Genesis Community Health. PhoneThis field is for validation purposes and should be left unchanged. Δ
