Volunteer Application

Please note that all volunteer opportunities require completion of this application and a separate criminal background check as part of the application process.

Name

First NameLast Name

Name you prefer to go by

Date of Birth (MM/DD/YYYY)

Date

Home Address

City

State

Zip

Phone

Email

example@example.com

How do you prefer to be contacted?

CallTextEmail

Contact Name

Relationship

Phone

Current Employer

Industry

Position

Work Address

City

State

Zip

Work Phone

May we contact you at work?

YesNo

Does your employer have any of the following?

A matching gift programAllotted time for volunteer workRecognition program for individuals who volunteer

How did you hear about Project 4031?

In a few words, describe yourself and what motivated you to volunteer with us at this time in your life?

Do you speak a second language? If so, what?

Describe any volunteer work with other organizations or other community involvement/offices held.

Please list your special skills, training, hobbies, or interests.

Do you have any ideas or other relevant information to share with us?

Please describe your availability to volunteer (such as a weekly or monthly basis and include days of the week and hours you are able to commit which best fit your schedule).

Volunteer Opportunities (Please check all areas of interest)

Serve Families: help research, plan, and coordinate with us to serve families within our service areas to the best of our ability.Connect with Families: reach out to families by writing personal notes or calling them.Spreading Joy Flower Program: coordinate with local businesses/vendors to collect flowers, create floral arrangements, and distribute to local hospice patients.Sponsor a Family for the Holidays: support a family in need for the holidays such as meals, gifts, etc.Collect/Distribute/Inventory Medical Equipment and Supplies: pick up or drop off donations in the DFW area and/or assist with organization and inventory of donated items.Special Events: plan and coordinate successful fundraising events by working on event committees, helping with preparations on the event day, and/or participating in the event.Administrative Assistance: answering phones, filing, data entry, bulk mailings, etc.Translator/Interpreter: facilitate our work with non-English-speaking families on an as-needed basis.

Reference 1 Name

Phone

Organization/Business

Relationship

Reference 2 Name

Phone

Organization/Business

Relationship

Reference 3 Name

Phone

Organization/Business

Relationship

I affirm that the information provided on this form is true and correct. The information I have given may be verified by contacting my references named in this application, or by contacting any person or organization that may have information concerning me, or by conducting a criminal background check.

I have read and understand the various volunteer roles and I am able to perform those roles in which I’ve applied for. I understand this application will help in determining the best fit of my skills at Project 4031. I am volunteering my time for personal reasons and expect no compensation for the services I provide.

Signature

Date

HIPAA and Confidentiality Agreement

As a volunteer of Project 4031, you may have access to "confidential information". The purpose of this agreement is to help you understand your obligations regarding confidential information.

Confidential information is protected by Federal and State laws and regulations, including HIPAA, as well as Project 4031 policies. The intent of these laws, regulations, standards and policies is to ensure that confidential information will remain confidential; that is, it will be used only as necessary to accomplish the purpose for which it is needed.

As a volunteer, you are required to conduct yourself in strict compliance with standards and regulations regarding confidential information. You may have access to confidential information, which includes, but is not limited to, information relating to:

Client information: name, all contact information, medical information, conversations, demographic information, and financial information. Protected Health Information (PHI) as defined by HIPAA includes, but is not limited to: names, all geographic subdivisions; all elements of dates (except year) for dates directly related to an individual, telephone numbers, fax numbers, electronic mail addresses, social security numbers, medical record numbers, health plan beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers, device identifiers and serial numbers, web universal resource locators (URLs), internet protocol (IP) address numbers, biometric identifiers, including finger and voice prints, full face photographic images and any comparable images; and any other unique identifying number, characteristic, or code. Employee information: name, address, social security number, or employment records. Donor information: name, all contact information, or donation amount. Project 4031 information: financial and statistical records, strategic plans, internal reports, memos, contracts, quality and peer review information, and communications.

I do affirm that I will not divulge information to any unauthorized person for any reason. Neither will I directly nor indirectly use, or allow the use of, information for any purpose other than that directly associated with my official assigned duties. I understand that all individually identifiable information of clients and donors is strictly confidential. Furthermore, I will not, either by direct action or by counsel, discuss, recommend, or suggest to any unauthorized person the nature or content of any information. I understand that my obligation to safeguard client and donor confidentiality continues after I am no longer a volunteer.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the agreement, I acknowledge that Project 4031 may, as applicable and as it deems appropriate, pursue disciplinary action up to and including dismissal of volunteer duties. In addition, violation of this agreement may lead to civil and criminal penalties under HIPAA and potentially other legal action.

Signature

Date

Volunteer Application

Emergency Contact Information:

Availability

References