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Are you at least 18 years old? *

Yes - I am at least 18 years old

No - I am younger than 18

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If you are not 18, we cannot accept you as a volunteer at this time.

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Date of Birth

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Birthday *

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First Name *

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Last Name *

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Preferred Name *

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Pronouns *

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Email *

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Phone Number

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Phone 1 *

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City *

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Zip/Postal Code *

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Why are you interested in volunteering with TOFC? *

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How are you interested in volunteering with us? *

Non-Medical : (Administrative)

Provider: MD, DO, PA, ARNP, Pharmacist, Therapist, Psychologist, PT, etc.

Medical: RN, LPN

Medical (Administrative): CNA, MA, EMT

Translator

Other

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If Other, please specify:

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Please upload your credentials

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Copy of State Medical License

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Providers need a professional resume- please upload below.

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License #

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Malpractice Insurance: Please click the following link and fill out the form to get free malpractice insurance through Washington State’s Volunteer and Retired Providers (VRP) Program! This is a requirement for all TOFC medical providers. Click ‘yes’ after you complete the form. https://www.tfaforms.com/4743992

Yes

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Professional Reference (Name, First and Last)

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Professional Reference (email)

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Professional Reference (Phone Number)

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Please specify which languages you can translate:

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Dietary restrictions/preferences *

If you don't have any, please put "N/A".

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Do you have any past or present criminal convictions, including felonies or misdemeanors? *

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Emergency Contact (Name, First and Last) *

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Emergency Contact (Phone Number) *

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First and Last Name of Personal Reference *

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Relationship to you *

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Reference Email *

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Reference Phone Number *

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Consent to Background Check *

I agree to both a police background check and state licensure verifications as needed. I understand that I will be provided a copy of the results of the Washington State Patrol background check upon my request.

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Confidentiality Agreement *

Notice of Immunity pursuant to the Defend Trade Secrets Act of 2016. An individual shall not be held criminally or civilly liable under any federal or state trade secret law for the disclosure of a trade secret that is made: 1) in confidence to a federal, state, or local government official, either directly or indirectly, solely for the purpose of reporting or investigating a suspected violation of law; 2) in confidence to an attorney, solely for the purpose of reporting or investigating a suspected violation of law; or 3) in a complaint or other document filed in a lawsuit or other proceeding, if such filing is made under seal. Furthermore, an individual who files a lawsuit for retaliation by an employer for reporting a suspected violation of law may disclose the trade secret to the attorney of the individual and use the trade secret information in the court proceeding, if the individual: 1) files any document containing the trade secret under seal; and 2) does not disclose the trade secret except pursuant to court order. I understand that all information I am exposed to regarding patients, volunteers, and/or family members at The Olympia Free Clinic, and its partners/collaborators, may be governed or protected by federal, state and/or local regulations and, where privileged, is to be held in the strictest confidence. No privileged information will be discussed with family, friends, or any other unauthorized person. I may release only information that is duly authorized for release and for which I have training and authorization to release. Unauthorized disclosure of sensitive information is cause for termination of volunteer services as well as possible civil and/or criminal sanctions. Furthermore, I hereby agree to: Institute or comply with appropriate procedures for safeguarding sensitive information and will hold discussions only in places which assure privacy, sharing information on a need-to-know basis. Resist any effort or request for information that is protected by relevant federal, state, and/ or local regulations. Not divulge, publish, or otherwise make known to unauthorized persons or the public any confidential information obtained in the course of my participation with clinic activities.

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Behavioral Agreement *

Thank you for your interest in volunteering at The Olympia Free Clinic, hereafter referred to as TOFC. Before being placed in a volunteer position, there are some important guidelines that you should be aware of. Volunteering is a fun and rewarding experience, but it requires commitment and consideration that patients, staff, and other volunteers are relying on you. All volunteers are expected to honor the following statements. Please review them carefully prior to your volunteer orientation and feel free to ask any questions that you may have at that time. As a volunteer at TOFC, I agree to: Report on time for my scheduled shift. Alert staff as soon as possible if you cannot work a scheduled shift. Comply with TOFC policies, protocols, and procedures and ask a TOFC staff member for clarification or confirmation of policies, protocols, and procedures before taking any actions, if in doubt. Maintain patient confidentiality. Report any incidents, concerns, or disputes immediately to a TOFC staff member. Uphold and embody the values of TOFC, including, but not limited to, respect, compassion, collaboration, competence, and advocacy. Adhere to and uphold TOFC's nondiscrimination statement: "The Olympia Free Clinic does not and shall not discriminate based on race, color, religion (creed), gender, gender expression and identity, age, national origin (ancestry), disability, including mental health diagnoses, marital status, sexual orientation, military status, substance use history, or housing status in any of its activities or operations. Furthermore, The Olympia Free Clinic pledges to treat all people with equal respect regardless of perceived differences. We are committed to providing a physically, emotionally, and psychologically safe and inclusive environment for all."

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