Volunteer Application Volunteer Application X/TwitterThis field is for validation purposes and should be left unchanged.Contact InformationName(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Birthday(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact(Required)Emergency Contact Phone(Required)What are your preferred days to volunteer?(Required) Mondays Tuesdays Wednesdays Thursdays Fridays What are your preferred hours to volunteer?(Required) Mornings Afternoons Evenings Skills/CertificationsPlease list any special skills, training or expertise that you have (medical, specialty, carpentry, painting, computer graphics, fundraising, etc.)Please list all languages you speak.Where else do you currently work or volunteer and what do you do there?Area of InterestVolunteer Area(Required) Clinical Position (Physician, Nurse, Social Worker, Mental Health Worker, etc.) Administrative (Clerical, Scheduler, Scanner, Translator, etc.) Clinical Positions Nurse/Clinical Assistant (RN, NP, MA, etc) Patient Case Worker Social Worker Mental Health Services Select Your Certificate Level APRN TN MA NP RT NA LPN Other Is Your License Active?YesRetiredInactiveState Licensed InAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCurrent License No.Administrative/Patient Relations Positions: Greeter: Patient Sign-In, Assist Patient with Paperwork, Requires no Computer Work Screener: Interviews patient for eligibility, enters data into computer Scheduler: Schedules appointments on computer Scanner: Scans documents into medical records Fundraising Events Community Events Volunteer Code of ConductThe primary mission of Bluffton Jasper County Volunteers in Medicine (BJVIM) is to understand and serve the health and wellness needs of the medically underserved population living and/or working in greater Bluffton and Jasper County. In working with our patients, their confidentiality is of utmost importance to the work we do here. I shall: 1. Uphold the philosophy and standards of BJVIM; 2. Not seek to obtain confidential information from a patient unless it is in the course of my job responsibilities; 3. Maintain all information that I obtain concerning patients, doctors and staff as confidential. 4. Conduct myself with dignity, courtesy and consideration of others, and endeavor to be professional; 5. Be punctual, conscientious and dependable; 6. Make my best effort to fulfill my commitment to BJVIM by completing all assignments; and 7. Bring to the attention of the Volunteer Coordinator any problems that impact my ability to meet the above standards, or that impact the BJVIM standards. I agree to: 1. Wear my ID badge; 2. Review the schedule and alert the Volunteer Coordinator of any scheduling conflicts; and 3. Submit to immunizations (TB, Hepatitis B, etc.) that may be necessary. I understand that BJVIM reserves the right to terminate my volunteer status as a result of: 1. Failure to comply with BJVIM policies, rules and regulations; 2. Excessive absences without prior notification; 3. Unsatisfactory behavior or attitude not in the spirit of VIM; and 4. Any other circumstance that would make my continued service contrary to the best interest of BJVIM.Terms and Conditions(Required)By clicking above, you are submitting this as your electronic signature. I have read each of the above conditions and agree to abide by them. Δ
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