Care Harbor Volunteer Registration |
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Contact Information
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Abbreviated Title |
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Example: Mr., Ms., Dr., Hon., Mx. |
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Professional Abbreviations |
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Example: DDS, MD, PhD |
Name on Badge |
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List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam |
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If possible, we would like to text you with occasional reminders and pertinent updates. |
Mailing Address Line 1 |
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Include apartment, suite or box number, if applicable. |
Mailing Address Line 2 |
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We recommend an email address unique to the registered volunteer instead of a shared office address or the personal address of a group leader for all group members. We will send personalized scheduling correspondence to this address. |
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Establish your unique User Name. You may use your email address as your User Name unless another registered volunteer will be receiving correspondence at that same address. |
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Used to recall your information when you visit this site again so you can make changes and/or select additional volunteer opportunities. Your password must be at least 8 characters and contain at least one letter and one number. It may not contain the characters < ' & * # . |
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Required Age |
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For legal reasons these are the age restrictions for volunteering. |
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Demographics and Background
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T-Shirt Size |
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T-Shirt style is adult unisex. Note that t-shirts may not be provided at all events. |
Language Fluency (other than English)
Select all that apply
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Hold down the control key to select more than one language.
Hold down the control key and click on a selected language to de-select it. |
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Other Information |
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Company / Organization |
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Optional, but helpful to know especially if you're coming with an office or team. |
Matching |
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Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer. |
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Description |
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Describe the program requirements and let us know how we can help - provide information for anyone we must contact and/or list any documentation you might need etc. |
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Emergency Contact
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First and Last Name |
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Relationship |
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Phone |
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Profession or Volunteer Classification
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Event Area |
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Select the event area appropriate to your profession / classification. |
Profession / Classification |
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License Number |
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Enter "none" if a license is not required for your profession. Set the Expiration Date in the future.
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Expiration Date |
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Prof. Liability Insurance Carrier |
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If your professional insurance does not cover you at this event, we will provide free liability coverage. Enter "Care Harbor" for your insurance carrier. |
State of Licensure |
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Only U.S. licensed professionals may volunteer as healthcare providers. Out-of-state providers must follow required procedures for license approval. |
License Comment |
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List additional information we should know. Examples: You selected Other Professional - indicate field/specialty. Your license will renew before the clinic. You are licensed in a second field - provide license details. |
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Residency Location |
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Residency Supervisor |
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We welcome medical, nursing, dental, and optometry student volunteers at Care Harbor. Please read the following instructions carefully. - Schools wishing their students to participate must be pre-approved for registration. Students cannot be confirmed until the student instructor has contacted us and the class has been approved.
- Once the school is approved, students must register individually on this site.
- Students must state their school and supervising instructor when they register or they cannot be confirmed.
- Please email us at volunteer@careharbor.org for school approval and for answers to any questions.
Note: If you are a healthcare student and will not be accompanied by a licensed faculty member, you can sign up as a General Volunteer and we will make every effort to place you in a support role in your professional area.
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School |
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Field of Study / Degree Program |
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Year of Study |
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Onsite Faculty Supervisor |
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Limit Event List by State? |
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Select a state to limit the list to only events in that state. |
Event |
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Select the Care Harbor event. |
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Event Location |
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More detailed directions will be available prior to your arrival. |
Event Email |
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Please add this information to your safe senders/callers list. |
Event Phone |
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Event Information |
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Please select an assignment for each day you plan to attend. - Waiting Lists: if your preferred assignment is full, a waiting list option may be shown. If you choose to be on the waiting list for your preferred assignment, you will also be given the option to select an alternate assignment. If an opening becomes available in your preferred assignment, you will receive an email notice (and, if selected, a text message) automatically moving you to your preferred assignment. This will automatically cancel you from the alternate assignment.
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Assignment Specific Questions (If Any)
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Optional Profile Picture
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Select your profile picture |
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You may optionally upload a profile image. Just skip this option if you do not care to share an image. We accept GIF, JPG, and PNG images. |
Your current picture |
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Upload Volunteer Documents (if needed for your assignments)
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If you have been directed to upload a document of some kind please do so below. This is otherwise not necessary.
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No files have been uploaded
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Volunteer Agreement
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Please read the following and indicate your agreement by signing electronically. Volunteers must agree in order to take part in the Care Harbor Free Clinic CONFIDENTIALITY I understand that while I am participating as a registered volunteer at the Care Harbor Free Clinic, it is mandatory that I maintain the privacy and confidentiality of all patients. This obligation includes all present and future verbal, written and digital communications referring to any Care Harbor Free Clinic patients. I also understand that unless I am obtaining information strictly for patient registration, I shall not ask a patient any questions regarding health insurance coverage, Medicare, Medicaid or other coverage. I further agree not to photograph or record patients while at the Care Harbor Free Clinic. RELEASE AND INDEMNIFICATION I hereby release Care Harbor, a 501(c)(3) nonprofit entity, and all of its officers, directors, employees, agents, volunteers, contractors, heirs, successors and assigns (hereinafter the "Released Parties") from prosecution and presentation of any claim for bodily injury, damages, wrongful death or for property loss or damage incurred in connection with my attendance and/or performance of services at the Care Harbor Free Clinic. I understand that I am volunteering at my own risk and that due to my occupational and/or other possible exposure to blood or other potentially infectious materials, I may be at risk of acquiring HIV, Hepatitis B or C virus, or other blood borne pathogens. I hold the Released Parties harmless in the event that I test positive for any such diseases as a result of my activities at the Care Harbor Free Clinic. COVID-19 I hereby attest that I have or will have received the recommended full course of Pfizer, Moderna, or Johnson&Johnson COVID-19 vaccine, including recommended booster shots, prior to my attendance at the Care Harbor Free Clinic. I understand and acknowledge the contagious nature of COVID-19. I voluntarily assume the risk that I may be exposed to COVID-19 as a result of my attendance and participation at the Care Harbor Free Clinic, whether due to my actions or omissions or the actions and omissions of others. I hold the Released Parties harmless in the event that I am exposed to or infected by COVID-19 as a result of my attendance and activities at the Care Harbor Free Clinic. PHOTO RELEASE I understand that film and video crews and photographers may be present at times during the event. I consent to being photographed, filmed, videotaped or recorded and grant my permission to use my image and likeness in any media for any lawful purpose in connection with Care Harbor or the Care Harbor Free Clinic without compensation to me. However, I reserve the right to refuse to be interviewed or to perform any action requested for purposes of photography, filming or videotaping unless I have given my express consent. If I am volunteering to work as a healthcare professional providing patient care at the Care Harbor Free Clinic, I further agree to the following: COMPLIANCE I hereby attest that my license/certificate is currently in force and not restricted, suspended or revoked. PATIENT-PHYSICIAN RELATIONSHIP I hereby assert and agree that no patient-physician relationship will be established with any of the patients whom I treat, examine or consult with at the Care Harbor Free Clinic, and that any such treatment, examination or consultation shall not be sufficient to establish the contract - express or implied - that creates the patient-physician relationship. I understand and agree that patients attending the Care Harbor Free Clinic will expressly waive any claim to a patient-physician relationship. With my electronic signature below, I acknowledge that I have read, understand and agree to all the terms of this Volunteer Agreement for the Care Harbor Free Clinic.
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Sign in the space below: |
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Please use your mouse to sign on a PC or use your mobile device touch screen
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Save and Submit - To Generate Confirmation
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Thank you for registering as a volunteer.
Upon clicking the SAVE AND SUBMIT button, you will be emailed a confirmation of your registration/updates.
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