Please complete this form and return to the following address with any necessary documentation:

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Jane Barrett
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1 Please complete this form and return to the following address with any necessary documentation: Tamiko Burgess Phone , ext.12 Center for Black Women s Wellness Fax Windsor St., SW, Suite 309 tburgesse@cbww.org Atlanta, GA ******************************************************************************************************************* VOLUNTEER APPLICATION - MEDICAL/PROFESSIONALS Name Date Emergency Contact Phone Home address City, State, and Zip Date of Birth Home phone Occupation Name of employer Employer address City, State, and Zip Phone Are you professional licensed in the state of Georgia? What is your specialty? If so, please answer the following questions: Professional license number of your professional license, front and back. Please attach a copy Malpractice carrier (if applicable) Please attach a copy of your coverage page. Do you speak a foreign language? If so, please indicate language. How did you hear about the Center for Black Women s Wellness? What interests you about volunteering here at the Center?

2 Page 2 of 4 Are you completing these volunteer hours for school or other community requirement? If so, please complete the following questions: School Area of study and year Requirements of volunteer experience (necessary hours, duties, etc.) Supervisor s name, title, and phone number Please attach any necessary paperwork. Is there anything else that you would like for us to know about you? Present or previous volunteer experience How often would you like to volunteer and in what area? Which program (s)/activities are you interested in being involved as part of your experience? Askable Adults Workshops (parent workshops) Wellness program Health Education (list topics of interest below) Summer Youth Leadership Training Program (leadership and life skills training for youth) Women s Economic Self- Sufficiency Program (micro- business training program) Wellness program Wellness Clinic (women s healthcare services) Atlanta Healthy Start (case management and health - primary education for pregnant and postpartum women) Wellness program Safety Net clinic ) healthcare for uninsured, low- income women and men Other Select any skills that you can provide: Primary Care Physician RN Ob/GYN Physician Medical Assistant LPN Other Special skills or hobbies Page 2 of 5

3 Availability (list actual times): Please indicate preferred days and times. 9am 5pm Monday Tuesday Wednesday Thursday Friday Saturday AM PM *Some programs meet in the evenings. Please specify which days you are available after 5 pm. ** Indicate if volunteering will be offsite. VOLUNTEER CONFIDENTIALITY AGREEMENT CENTER FOR BLACK WOMEN S WELLNESS Page 3 of 5

4 I understand that the Center for Black Women s Wellness has a legal and ethical responsibility under the Health Insurance Portability and Accountability Act s Privacy Rule to maintain patient privacy, including obligations to protect the confidentiality of patient information and to safeguard the privacy of patient information. In addition, I understand that during the course of my assignment/affiliation with the Center for Black Women s Wellness, I may see or hear other Confidential Information such as financial data and operational information pertaining to the practice that the Center for Black Women s Wellness is obligated to maintain as confidential. As a condition of my assignment/affiliation with the Center for Black Women s Wellness, I understand that I must sign and comply with this agreement. By signing this document I agree that: I understand that any Confidential Information or Patient Information that I access or view at the Center for Black Women s Wellness does not belong to me. I will not disclose or discuss Patient Information and/or Confidential Information. I will not access or view any information other than what is required to do my job. If I have any question about whether access to certain information is required for me to do my job, I will immediately ask the Privacy Official for clarification. I will direct inquiries about any and all practice information to the Privacy Official only. I understand that it is not acceptable to discuss any practice information in public areas even if specifics such as a patient s name are not used. I will not make any unauthorized transmissions, copies, disclosures, inquiries, modifications, or purging of Patient Information or Confidential Information. Such unauthorized transmissions include, but are not limited to, removing and/or transferring Patient Information or Confidential Information from the Center for Black Women s Wellness to unauthorized locations. I agree that my obligations under this agreement regarding Patient Information will continue after the termination of my assignment/affiliation with the Center for Black Women Wellness. Page 4 of 5

5 I understand that violation of this Agreement may result in disciplinary action, up to and including termination of my assignment/affiliation with the Center for Black Women s Wellness, as well as potential personal civil and criminal legal penalties. I have read the above agreement and agree to comply with all its terms as a condition of continuing affiliation. Signature Date Volunteer Areas that apply to me while at Center for Black Women s Wellness. Please check all that apply. Front Office Back Office Dispensary Counseling Medical Assistant Interpreters Student Intern MD/NP/PA Signature Date Page 5 of 5

Volunteer Driver Application Form

Road to Recovery Volunteer Driver Application Form Please Print Name: Street Address: City State Zip: Other Address Information/ Email: Home Phone: Work Phone: Date of Birth: Occupation: Emergency Contact