Community Initiatives, Inc. Volunteer Application
Please complete this form in order to register as a volunteer for Community Initiatives, Inc's La Clinica Gratis/The Free Clinic.  You will receive an email with information regarding completing your volunteer application and an orientation after this form is completed.

If you have any questions please call Curesa Clark Program Coordinator, at 864-223-7472, ext. 7 or email her at curesa@myci.us 

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Email *
Please enter the date of completion. *
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Name: First and Last *
Phone Number *
Address: *
As a volunteer of Community Initiatives Inc., I understand and acknowledge that: I must hold confidential and private all information pertaining to clients/patients, patient records, client facility policies, and procedures. All protected patient information shall be kept safeguarded pursuant to the policies and procedures at each facility, respectively and in accordance with the Health Information Portability and Accountability Act of 1996 (HIPPA), the regulations issued there under, and any applicable state law to prevent impermissible disclosure, loss or misuse, and to ensure that only authorized persons have access to such protected information. Private and confidential information will only be released to an outside party when legally required to do so and to the extent minimally necessary to respond to the request. Failure to maintain confidentiality and privacy may lead to disciplinary action; I understand that any breach of confidentiality may be grounds for immediate termination of volunteer services as well as any appropriate legal actions. *
South Carolina law requires that certain professionals report suspected cases of child abuse or neglect. Because they have unique opportunities to observe and interact with children, the following professionals are mandated reporters of child abuse or neglect: physicians, nurses, dentists, optometrists, medical examiners or coroners or their employees, emergency medical services, mental health or allied health professionals, teachers, counselors, principals, school attendance officers, social or public assistance workers, substance abuse treatment staff, childcare workers, foster parents, police or law enforcement officers, juvenile justice workers, volunteer non-attorney guardians ad litem serving on behalf of the South Carolina Guardian ad Litem program or on behalf of Richland County CASA, undertakers, funeral home directors or their employees, film processors, computer technicians, judges, and clergy, including Christian Science Practitioners or religious healers (subject to laws governing privileged communication). The law encourages all persons to report.                                                 When to Report:                                                                  Mandated reporters must report abuse or neglect when, in their professional capacity they receive information giving them reason to believe that a child’s physical or mental health has been or may be adversely affected by abuse or neglect. A decision to report must be based upon a reasonable belief that a child has been or may be abused or neglected. Thus, mandatory reporters need not have conclusive proof that a child has been abused or neglected prior to reporting abuse or neglect to the proper authorities.  A person who is required to report and fails to do so is guilty of a misdemeanor. Upon conviction, he or she may be fined up to $500 or imprisoned up to six months, or both.  As a volunteer of Community Initiatives, Inc., I am aware of and pledge to follow the guidelines regarding abuse, neglect, or harm as outlined in SC Code 63-7, known as the Children’s Code. *
Participating School (Students Only)
List Major (Students Only)
Classification (Students Only; Freshman, Sophomore, Jr., Sr., etc)
Lander University Students ONLY: Please select the class(es) you are volunteering for credit in:
Volunteer duties you are interested in: *
Required
Background Check: Have you completed a SLED check in the past two years? *
Choose the days you are available? *
Required
Choose which times you are available? *
Required
Are you bilingual (English/Spanish)? *
Have you been vaccinated for COVID-19 *
I certify that I will follow all medical, ethical, HIPAA, and mandated reporting guidelines. I agree to hold free any claims against Community Initiatives, Inc., their agents, employees, volunteers, directors, administrators, and other such affiliates by signing this document. I agree to follow all guidelines as outlined in the Community Initiatives, Inc. Policy and Procedure Manual which I will revive electronically before I begin my volunteer service. I understand I am in a learning environment and will adhere to all guidelines of my institution’s expected standards. I agree to contact Teresa Goodman, Executive Director of Community Initiatives, Inc. concerning any issues as the authority and decision maker for La Clinica Gratis/The Free Clinic or CINC at 864-223-7472, ext 8 or tgoodman@myci.us 
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