Volunteer Application

Bloom Pediatrics Volunteer Application

If you would like to volunteer with us, please submit your application. Because we are a unique family-centered private practice, we require a trial day prior to accepting volunteers for an ongoing basis. Thank you for your interest!

Volunteer Guidelines
Please carefully read the volunteer guidelines listed below. Contact us if you have questions regarding any of these guidelines.*

I understand that Bloom does not guarantee the fulfillment of the required hours for occupational therapy program applications.I understand that Bloom does not provide letters of recommendation for volunteers unless they have volunteered with us consistently FOR AT LEAST 40 HOURS.I understand that letters of recommendation are NOT GUARANTEED from Bloom therapists.I understand that volunteers must complete a trial day prior to being accepted on an ongoing basis.I understand that accepted volunteers agree to a TWO (2) WEEK TRIAL PERIOD to ensure goodness of fit.I understand that volunteers must commit to a consistent schedule. Volunteers must demonstrate responsible and professional behavior (e.g., arrive on time, follow dress code).I understand that primary volunteer duties must be completed before the observation of any therapy sessions.

Volunteer Information
Name*

First NameLast Name
Email*
Primary phone*
How did you hear about us?*
LinkedIn
Please upload your resume (optional).

Cancelof
College or university*
Degree(s) in progress or completed*
Graduation date (actual or anticipated)*
Current employer
How long have you worked with this employer?
Job title and description of duties.
Please describe your interest in Bloom Pediatrics. Why are you hoping to volunteer with us?*
Please describe skills you have that might contribute to our setting.*

General Availablity

Please check when you are available to volunteer with us. Check all options that apply. Keep in mind that our site requires that volunteers maintain a consistent weekly schedule in 3-4 hour blocks of time (e.g., 8:30am-12:30pm, 1pm-4pm).*

	Mornings only	Afternoons only	Mornings or afternoons	Not available	Other schedule information
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

Required Forms
Volunteer Waiver*

I attest that I understand and agree to the following: I, the above listed Volunteer, desire to volunteer for Bloom Pediatrics and engage in the activities related to being a volunteer. I hereby voluntarily, execute this Volunteer Waiver under the following terms: I release and hold harmless Bloom Pediatrics and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my volunteer work with Bloom Pediatrics. I understand that this Waiver discharges Bloom Pediatrics from any liability or claim that I may have against Bloom Pediatrics with respect to bodily injury, personal injury, illness, death, or property damage that may result from my participation on the Bloom Pediatrics work site. I also fully understand that Bloom Pediatrics does not assume any responsibility for obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage. I understand that I expressly waive any such claim for compensation or liability on the part of Bloom Pediatrics beyond what may be offered freely by the representative of Bloom Pediatrics in the event of such injury or medical expense. I hereby release Bloom Pediatrics from any claim whatsoever which arises or may arise in the future on account of any first aid treatment or other medical services that are conducted in connection with an emergency during my time with Bloom Pediatrics. I understand that my time with Bloom Pediatrics may include various activities that may be hazardous to me and I hereby expressly and specifically assume the risk of injury or harm in these activities and release Bloom Pediatrics from all liability for injury, illness, death, or property damage resulting from the activities of my time with Bloom Pediatrics. I grant unto Bloom Pediatrics all right, title, and interest in any and all photographic images and video or audio recordings that are made by Bloom Pediatrics during my work with Bloom Pediatrics, including, but not limited to, any royalties, proceeds, or other benefits that are derived from such photographs or recordings. I expressly agree that this Waiver is intended to be as broad and inclusive as permitted by the laws of the State of California in the United States of America, and that this Waiver shall be governed by and interpreted in accordance with the laws of the State of California. I agree that in the event that any clause or provision of this Waiver shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to enforceable.
Confidentiality Agreement*

I attest that I understand and agree to the following: As a volunteer with Bloom Pediatrics I may have access to confidential information. I am required to conduct myself in strict conformance with applicable laws, standards, regulations, and Bloom Pediatrics Polices governing confidential information. The purpose of this Confidentiality Agreement is to help me understand my obligations regarding confidential information. Confidential information is protected by Federal and State laws, regulations, including HIPAA, the Joint Commission on Accreditation of Healthcare Organizations standards, and Bloom Pediatrics Policies. The intent of these laws, regulations, standards, and policies is to ensure that confidential information will remain confidential – that is, that it will be used only as necessary to accomplish the purpose for which it is needed. My principal obligations are explained below. I am required to read and to abide by these rules. I understand that anyone who violates this confidentiality agreement will be subject to discipline, which might include, but is not limited to, termination of any affiliation or relationship with Bloom Pediatrics. In addition, violation of these rules may lead to civil and criminal penalties under HIPAA and potentially other legal action. I will only use confidential information/data as needed to perform my duties as an employee, student, or volunteer with Bloom Pediatrics. I will not in any way divulge, copy, release, sell, loan, review, alter or destroy any confidential information/data except as properly authorized within the scope of my activities affiliated with Bloom Pediatrics. I will not misuse confidential information/data or be careless with it. I will report activities by any individual or entity that I suspect may compromise the confidentiality of information. Bloom Pediatrics will make all attempts possible to keep good faith reports confidential. However, absolute confidentiality cannot be guaranteed. I understand that my obligations under this agreement will continue after my affiliation with the Bloom Pediatrics ends. I understand that I have no right or ownership interest in any confidential information/data. I understand that Bloom Pediatrics may at any time revoke my access to confidential information/data. I will be responsible for my misuse or wrongful disclosure of confidential information and for my failure to safeguard confidential information/data or any other authorization that allows me to access confidential information/data. I agree that I will not disclose private information of Bloom clients to anyone. I agree I will not record or take pictures of Bloom clients. I agree I will not post identifying information about Bloom clients to social media. I agree that I will not discuss any information pertaining to any Bloom client in any place where it can be overheard by anyone (e.g., grocery store, workplace, school). I agree that I will not disclose any information that may help to identify Bloom clients, including but not limited to, names, physical descriptions, biological information, and specifics of the content of interactions with other Bloom employees, students, or volunteers. I agree that I will not release any information, in writing or orally, regarding any Bloom client to any person(s) or agencies.
COVID-19 Release of Liability*

I attest that I understand and agree to the following: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Bloom has put in place preventative measures for both on-site and off-site activities to attempt to reduce the spread of COVID-19, such as the following: Providing therapists, volunteers, students, and other staff with protective masks to be worn while engaging in activities at Bloom Pediatrics; therapists will have masks to don during in-home sessions, decisions regarding wearing the mask will be discussed and agreed upon between therapist and client; therapists, volunteers, students, and other staff will have access to latex gloves; avoiding gatherings of more than 10 people by scheduling clinic sessions at staggered time slots; limiting the number of employees and clients on site at a time; mandating parent curbside drop-off and pick up at clinic; temperature and symptom checks for employees, staff, and children at clinic; frequent, scheduled cleaning and sanitizing of therapy spaces, toys, and equipment throughout the day at clinic; frequent, scheduled handwashing before and after session (on-site and off-site). However, Bloom Pediatrics cannot in any way guarantee that you or your child(ren) will not become infected with COVID-19. Acceptance of Risk; Release; Indemnification. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) is at risk for exposure or infection by COVID-19 by attending scheduled on-site or off-site activities related to Bloom Pediatrics and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Bloom Pediatrics may result from the actions, omissions, or negligence of myself and others, including, but not limited to, therapists, volunteers, and other participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren), family members, or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance or participation at Bloom Pediatrics activities and programming (“Claims”). On my behalf, and on behalf of my children, I hereby forever release, covenant not to sue, discharge, waive, relinquish, and hold harmless Bloom Pediatrics, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, rights, costs, expenses, and causes of action of whatever kind or nature, and other losses of any kind, whether known or unknown, foreseen or unforeseen, out of or relating thereto, as a result of my child attending or participating in scheduled services, on-site or off-site, as related to Bloom Pediatrics, including but not limited to those related to the above described personal injuries, death, disease, disability, or any other loss. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Bloom, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Bloom Pediatrics related activity. I further promise not to sue Bloom Pediatrics or any Bloom Pediatrics representative, and agree to indemnify and hold them harmless from any and all damages resulting from my child’s participation in services at Bloom Pediatrics, including sessions held on and off site.
Parking Information*

I attest that I have read and agree to the following policies and procedures: Street parking is available throughout the neighborhood. In order to avoid a parking citation, Bloom strongly encourages volunteers to read posted signs for parking restrictions, and not block neighbors driveways. Bloom is not responsible for parking citations due to failure to abide by relevant parking restrictions.
Non-Discrimination Policy*

I attest that I have read and agree to the following policies and procedures: Bloom strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability. Volunteers are expected to participate in this endeavor and show mutual respect for members of our community.

Volunteer Signature and Date
By signing below, I attest that I understand and agree to the terms and conditions outlined above.*

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Bloom Pediatrics Volunteer Application