| Free Clinic Beacon House |
| St. Petersburg Free Clinic 863 3rd Avenue N. St. Petersburg, FL 33701 Phone 727.821.1200 Fax 727.821.9263 |
© Copyright 2008 St. Petersburg Free Clinic. All Rights Reserved.
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| VOLUNTEER AGREEMENT |
I agree to read and abide by the guidelines presented in the COMMUNITY
SERVICE PROGRAM and VOLUNTEER ORIENTATION handbooks. I also
understand that as a volunteer, I will receive no pay and will not be covered by any
insurance in connection with any possible injury while volunteering at the St.
Petersburg Free Clinic. I further hereby authorize the St. Petersburg Free Clinic to
seek emergency medical treatment in case of accident, injury or illness and to
hold harmless the agency in the event of accident, injury or illness.
As a volunteer of the St. Petersburg Free Clinic, I agree that my photograph or
likeness may be used in internal and external promotional materials.
As a volunteer of the St. Petersburg Free Clinic, I also understand and agree that
all information as it relates to persons served by the agency is to be held
confidential in compliance with Florida and Federal Statutes and that information
that is confidential includes the client's name, address, medical, social and
financial data, and services received. I further understand that data collection by
interview, observation, or review of documents should be in a setting which
protects the client from unauthorized individuals, and that client information
should never be discussed outside the agency. All information that should come
to my attention and knowledge as privileged and confidential will not be disclosed
to anyone other than authorized personnel and that I shall conduct myself in
accordance with program security policies. I understand that failure to comply
may result in criminal prosecution.
SERVICE PROGRAM and VOLUNTEER ORIENTATION handbooks. I also
understand that as a volunteer, I will receive no pay and will not be covered by any
insurance in connection with any possible injury while volunteering at the St.
Petersburg Free Clinic. I further hereby authorize the St. Petersburg Free Clinic to
seek emergency medical treatment in case of accident, injury or illness and to
hold harmless the agency in the event of accident, injury or illness.
As a volunteer of the St. Petersburg Free Clinic, I agree that my photograph or
likeness may be used in internal and external promotional materials.
As a volunteer of the St. Petersburg Free Clinic, I also understand and agree that
all information as it relates to persons served by the agency is to be held
confidential in compliance with Florida and Federal Statutes and that information
that is confidential includes the client's name, address, medical, social and
financial data, and services received. I further understand that data collection by
interview, observation, or review of documents should be in a setting which
protects the client from unauthorized individuals, and that client information
should never be discussed outside the agency. All information that should come
to my attention and knowledge as privileged and confidential will not be disclosed
to anyone other than authorized personnel and that I shall conduct myself in
accordance with program security policies. I understand that failure to comply
may result in criminal prosecution.
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