• MEDICAL MISSION ADVENTURES

    Non-Clinical Volunteer Application for COVID-19 Vaccine Clinics
  • Please fill this form out completely before submitting it. We cannot process your application for volunteer service without the information requested AND:

    1. A copy of your driver license
    2. Your signature under the Statements of Affirmation
    3. Your signature under the Confidentiality Statement

    MMA Contact Information:

    • Email: mma@mmadventures.org
    • Phone: 818-890-3656
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  • Home Address:

  • REFERENCES:

  • Reference 1

  • Reference 2

  • PROFESSIONAL INFORMATION:

  • STATEMENT OF AFFIRMATION:

  • I affirm that:

    I have never been convicted of a felony, I have never been charged with sexual harassment, I have not and will not provide patient care under the influence of drugs or alcohol, I do not have any communicable disease, and I further understand that if at any time I am considered to be infectious I will notify the Clinic's medical director and/or executive director.

    In making this application, I acknowledge my obligation to:

    Abide by the bylaws, rules and regulations, policies and procedures of the Clinic.

    I hold the Clinic and its representatives free of all liability for my actions.

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  • CONFIDENTIALITY AGREEMENT

  • In consideration of my volunteerism with Medical Mission Adventures, Inc. (hereafter referred to as MMA), I recognize that confidentiality is vital to protect the privacy of our patients and staff. Also included are any issues that relate to the patient and staff. Therefore, I agree to respect and maintain the confidentiality of all discussions, deliberations, records, and other information generated in connection with all MMA activities whether oral, electronically, or written, and I understand that by signing this agreement I am binding myself by contract to maintain such confidentiality. I agree that I will not make any voluntary disclosure of such confidential information outside of MMA, limit dissemination of such confidential information to only those MMA employees/volunteers who have a need to know to perform their assigned tasks, not copy confidential information or any portion thereof except as required under my assigned duties, and return all such confidential information and any copy thereof upon termination of my service with MMA.

    I understand and agree that MMA shall have the right to seek and obtain from a court of competent jurisdiction, in an action for that purpose, an order and/or a judgment enjoining and prohibiting me from voluntarily disclosing confidential information in violation of this agreement. I agree that it is impossible to measure in money the damages which would result from my disclosure of confidential information in violation of this agreement and that irreparable injury would be caused thereby to MMA. I hereby waive any claim of defense that MMA has an adequate remedy at law, and I consent to the imposition of injunctive relief to prevent a breach of this agreement. MMA shall be entitled to recover attorney's fees and court costs from me in any such action in which they are successful.

    I understand that my obligations under this agreement will continue whether or not my service with MMA is terminated voluntarily, or with or without cause and shall continue to bind my successors, heirs, and assigns.

    This agreement may not be changed in any detail by any verbal statement, representation, or other Agreement made by any other MMA employee or volunteer, or by any written document signed by any MMA employee/volunteer other than a MMA officer.

    The law of the state of California will govern the interpretation, validity, and effect of this contract, without regard to the place of making or the place of performance.

    Further I state that: (a) I am legally competent to execute this agreement and I am above the age of eighteen (18) years of age; (b) No promise or agreement which is not expressed has been made to me in executing this release; (c) I am not relying upon any statement or representation of any agent of the parties being released; (d) I understand that the terms of this release are contractual and not mere recital; (e) I have had the opportunity to consult with legal counsel regarding the effect of this agreement and release should I so desire; and (f) I have fully read this release and have agreed to as my own free act and will.

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  • Thank you for applying to volunteer with Medical Mission Adventures!

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