Volunteer Application

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At Water City Care Mission, we believe that people have a right and a duty to participate in society, seeking together the common good and well-being of all, especially the poor and vulnerable.

To volunteer with Water City Care Mission...

1. Complete this volunteer application form.
2. Pass a background check.
3. Attend New Volunteer Orientation. This is required. Orientation is offered once per month.

Name *

Please enter your full name

Email *

Phone number *

Address *

Employer

Birthdate (required for background check) *

YYYY

What kind of volunteer activities are you interested in? Please check all that apply. *

Administrative and program support, e.g., data entry

St. Anne's Clinic Provider (Physician/APNP/PA)

St. Anne's Clinic Mental Health Provider

St. Anne's Clinic Nurse

St. Anne's Clinical Support

St. Anne's Clinic Advisory Committee

Water City Care Mission Board of Directors

Translation / Interpretation

Other

Other:

Required

If you checked "Translation," "Interpretation," or "Other," please list language(s) or other volunteer interests here:

Why would you like to volunteer with Water City Care Mission? What are some skills or experience that you would like to contribute and/or gain? *

Please describe your experience and interest in working with people living on low incomes from diverse backgrounds.

Do you give consent for Water City Care Mission, Inc. to complete a criminal background check based on the information you provided? *

Yes

Authorizations & Agreements *

I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary for the purposes of determining an appropriate and satisfactory volunteer position for me, including contacting my references. I understand that this application is not, and is not intended to be, a contract. I understand that false or misleading information provided in my application or interview may result in my not being able to continue as a volunteer with Water City Care Mission, Inc.

In checking this box and submitting this application, I acknowledge that I have read and understand WaterCity Care Mission's confidentiality policies. I understand and agree that in the performance of my duties as an employee or volunteer of Water City Care Mission, I must hold certain information regarding clients, employees, and volunteers in the strictest confidence. Further, I understand that confidentiality is protected by Federal law (42CF R Part II and Uniform Health Care Information Act), and that any intentional or involuntary violation of the confidentiality with regard to clients, employees, and/or volunteers may result in disciplinary action including suspension and/or termination.

I hereby release, indemnify, and hold harmless Water City Care Mission, Inc., Most Blessed Sacrament Parish, their officers, directors, and employees, and the organizers, sponsors, and supervisors of all Water City Care Mission, Inc. activities from any and all liability in connection with any injury I may sustain (including any injury caused by negligence) in conjunction with volunteering with Water City Care Mission, Inc..

In checking this box and submitting this application, I agree to be photographed, videotaped, and/or recorded while volunteering with Water City Care Mission, Inc. I understand that Water City Care Mission, Inc. will own rights to and may use this media (photographs, videos, audio recordings, and/or my statements), in whole or part, in Water City Care Mission, Inc. materials such as printed publications, the Water City Care Mission, Inc. website (www.watercitycaremission.org), videos, social media, grant proposals, and promotional materials to support Water City Care Mission, Inc. and its programs. As far as I know, what I say and do in this media will not violate the rights of any other person or company. If I no longer want my photos and/or story to be used, I agree to contact the Water City Care Mission, Inc. Communications Department at info@watercitycaremission.org. Once requested, Water City Care Mission, Inc. will not create new materials using participants’ media – but we may continue to use already printed materials until we can make replacements.

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