Thank you for your interest in volunteering with Care Harbor!

All volunteers must register on this site to participate in the event. After registering, you may return to this site to change your clinic assignment, shift times, or other information.

Your registration information will not be saved until you complete all sections and click SAVE AND SUBMIT at the end of this form.

If your plans change in the future, please use the RECALL MY INFORMATION button to pull up your assignments, and cancel your registration promptly so that another may take your place..

 
      If you previously registered on this webpage, we will recall your information.
Do not RECALL your information and type over it for another family member. That overlays the existing record.
 
 
Abbreviated Title   Example: Mr., Ms., Dr., Hon.
 
     
Professional Abbreviations       Example: DDS, MD, PhD
Name on Badge       List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam
 
 
  If possible, we would like to text you with occasional reminders and pertinent updates.
Mailing Address Line 1   Include apartment, suite or box number, if applicable.
Mailing Address Line 2  
 
 
 
  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.
 
        
  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. 
        
  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 6 characters.
 
       
Required Age
  I will be at least 18 years of age when I volunteer
  For legal reasons these are the age restrictions for volunteering.
 
T-Shirt Size   T-Shirt style is adult unisex.
Language Fluency (other than English)
Select all that apply
  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.
         
Other Information
    Blood Borne Pathogen Training    
          
Company / Organization   Optional, but helpful to know especially if you're coming with an office or team.
Matching
My company has a matching program
  Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer.
Description   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.
 
First and Last Name  
Relationship    
Phone    
   
Event Area
  Select the area appropriate to your profession / classification.
Profession / Classification
General Notes
(if needed)
 
License Number   Enter "none" if a license is not required for your profession. Set the Expiration Date in the future.
Expiration Date    
Prof. Liability Insurance Carrier   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   Only U.S. licensed professionals may volunteer as healthcare providers. Out-of-state providers must follow required procedures for license approval.
License Comment   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.
     
Residency Location  
Residency Supervisor  
     

We welcome medical, nursing, dental, and optometry student volunteers at Care Harbor.

Please read the following instructions carefully.

  1. 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.
  2. Once the school is approved, students must register individually on this site.
  3. Students must state their school and supervising instructor when they register or they cannot be confirmed.
  4. 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.

School    
Field of Study / Degree Program    
Year of Study    
Onsite Faculty Supervisor    
       
 
Event
  Select the Care Harbor event.
 
Event Location
---
  More detailed directions will be available prior to your arrival.
Event Email
---
  Please add this information to your safe senders/callers list.
Event Phone
---
 
Event Information
 
 
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.

    
Admin Code
For administrative or instructed use only.
Day Type Assignment
   
     
   
Select your profile picture   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
   
If you have been directed to upload a document of some kind please do so below. This is otherwise not necessary.
Document 1 Name      
Document 2 Name      
Document 3 Name      

No files have been uploaded

   
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 pertains to 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.

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.

Sign in the space below:
Please use your mouse to sign on a PC or use your mobile device touch screen
 
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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