HELP Volunteer Application

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Thanks for your interest in volunteering with Project Access of Durham County's Health Equipment Loan Program (HELP). Please fill out the following. For more information visit projectaccessdurham.org/projects/help.

Name *

Email *

Phone number *

Address *

Work History: Please list up to three of your most recent or relevant work positions. Include name of organization, dates of employment and job title. *

Volunteer History: Please list up to three of your most recent or relevant volunteer positions. Include name of organization, dates of volunteering and job title. *

Please list the names, phone numbers, and email addresses for two references. *

Please select any tasks you have experience or an interest in: *

Cleaning and sanitizing equipment

Repairing equipment

Customer service

Data entry

Speaking to community groups/tabling at fairs

Social media

Other (include below)

Required

How did you hear about HELP? *

Why do you want to volunteer with HELP? *

When are you available to volunteer? Select all that apply. *

Tuesdays from 10-12pm

Tuesdays from 12-2pm

Fridays from 1-3pm

Fridays from 3-5pm

Other (include below)

Required

Do you speak any language(s) other than English? *

Is there anything else you would like to mention? *

Volunteer agreement

I hereby certify the answers on this application and resulting from interview are true and correct. I understand that any misrepresentations or omissions of facts, misleading or false information on my part will be grounds for rejection of my application or termination of my volunteer status if such occurrence is discovered at a later date.

I am aware that Project Access does not provide insurance coverage for volunteers if personally injured or if damage occurs to personal property while acting as a volunteer. I further understand that I am not entitled to Worker’s compensation benefits, health insurance benefits, or any other benefit available to employees of Project Access. I agree that I will not hold Project Access or its officers or agents liable for any injury sustained to person or property while acting in a volunteer capacity.

I authorize my previous employers, personal references and other persons or institutions shown on this form to provide information upon request by Project Access. I hereby release any agency or person listed from any and all liability in conjunction with the release of said records and/or information.

I authorize Project Access to conduct a criminal background investigation.

Confidentiality

I agree to protect the confidentiality and proprietary information of patients and employees in any form (talking, paper, electronic).

I will ONLY access information that I need for my volunteer job.

I know that confidential information I learn on the job does not belong to me.

Yes, I agree

No, I disagree

Required

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