2024 MMA - Clinical Volunteer Application

TWO REFERENCES:
1)
Name*
Relationship*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
2)
Name*
Relationship*
Phone number*
Email*
TYPE OF PRACTICE:
PRIMARY PRACTICE INFORMATION (nurses included):
Practice Name*
Practice Address*
Mailing address if different from above:
Phone number*
Email*
example@example.com
Practice Manager*
SECONDARY PRACTICE INFORMATION, if applicable:
Practice Name
Address
Phone number
Email
example@example.com
Practice Manager
Page 2

FACILITY AFFILIATIONS (nurses included): (List current hospital/health system affiliation where you have been credentialed and privileged) Please put N/A if not applicable.
Facility Name*
Address*
Department/Service/Position:*
Dates Of Appointment (from/to)*
UNDERGRADUATE EDUCATION
Institution*
Location (city & state)*
Type of Degree(s)*
Date of Graduation*
PROFESSIONAL SCHOOL
Institution*
Location (city & state)*
Type of Training/Speciality*
Date of Graduation*
Full Name by which you were enrolled*
INTERNSHIP:
Institution
Address
Type of Training/Specialty
Date of Completion

MonthDayYear
Date
Full Name during internship
RESIDENCY:
Institution
Address
Type of Training/Specialty
Date of Completion

MonthDayYear
Date
Full Name during residency
LICENSURE & REGISTRATIONS *(List all active professional licenses):
License Information*
License Information
License Information
National Provider Identifier (NPI number)
Federal DEA Number
SSN or ITIN*
Needed to obtain malpractice insurance coverage.
Page 3

Confidentiality Agreement
In consideration of my volunteerism with Medical Mission Adventures, Inc. (hereafter referred to as MMA) and Acts of Mercy (hereafter referred to as AOM), 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/AOM 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/AOM, limit dissemination of such confidential information to only those MMA/AOM 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/AOM.

I understand and agree that MMA/AOM 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/AOM. I hereby waive any claim of defense that MMA/AOM has an adequate remedy at law, and I consent to the imposition of injunctive relief to prevent a breach of this agreement. MMA/AOM 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/AOM 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/AOM employee or volunteer, or by any written document signed by any MMA/AOM employee/volunteer other than a MMA/AOM 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.
Applicant's Name (print)*
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Page 6

I give my permission to Medical Mission Adventures, Inc. (hereafter referred to as MMA) and Acts of Mercy (hereafter referred to as AOM) to verify any information necessary pertaining to my volunteer application. I hereby release from liability MMA/AOM and all its representatives for their acts performed while evaluating my application, credentials and qualifications, including the gathering of necessary information from primary sources for the verification of professional

I hereby release from any liability any and all individuals and organizations that provide information to MMA/AOM or its representatives concerning my professional competence, character, ethics, credentials and other qualifications for employment and/or privileges, and I hereby consent to the release of such information.

As applicable, I hereby accept that I will abide by the requirements for medical malpractice coverage for the Federal Tort Claims Act. I will cooperate fully in all measures to improve quality and reduce risks, and with any investigations and defense of liability claims.

I understand that I have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications, and for resolving any doubts about such qualifications. I fully understand that any misstatements or omissions in the application constitute cause for denial or termination of privileges. All information submitted by me in this application is true to the best of my knowledge.
Authorization and Consent
Applicant's Name (print)*
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Thank you for applying to volunteer with Medical Mission Adventures/Acts of Mercy!
Should be Empty:

Clinical Volunteer Application

PERSONAL INFORMATION:

TWO REFERENCES:

1)

2)

TYPE OF PRACTICE:

UNDERGRADUATE EDUCATION

PROFESSIONAL SCHOOL

INTERNSHIP:

RESIDENCY:

CERTIFICATIONS:

IMMUNIZATION HISTORY

CLAIMS INFORMATION:

REQUIRED COPIES & REFERENCES:

STATEMENTS OF AFFIRMATION:

Confidentiality Agreement

Authorization and Consent