7985 Knight Road. Suite B Gainesville, Georgia 30506
770-781-4899 office 770-781-4094 fax
Volunteer Information Form and Health History
GENERAL INFORMATION
Name:______Date:______
Address:______
Employer/School:______
Email address:______Cell number: ______
Date of Birth:______Phone:______(home)______(work)
Parent/Guardian Name and Address: ______
______
How did you learn about the program?______
Emergency Contact Name: ______Phone Number:______
Tuberculosis test + - Date ______Last Tetanus shot: ______
CPR/First Aid Certification: Y N
Date of expiration: ______
Horse experience: Y N # of years______
Have you ever been charged with or convicted of a crime? Y N; please explain______
______
I, ______, authorize Finding Faith, Inc to receive information from any law-enforcement agency, including police departments, and sheriff's departments, of this state or any other state or federal government, to the extent permitted by state and federal law, pertaining to any convictions I may have had for violations of state or federal criminal laws, including but not limited to convictions for crimes committed upon children.
I understand that such access is for the purpose of considering my application as an employee/volunteer, and that I expressly DO NOT authorize Finding Faith Inc, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.
Signature: ______
Date: ______
HEALTH HISTORY
Please describe your current health status, particularly regarding the physical/emotional demands of working in a physical therapy, occupational therapy, speech therapy/hippotherapy program. Address fitness, cardiac, respiratory, bone or joint function, recent hospitalizations/surgeries, or lifestyle changes.
______
______
______
______
Medications: ______
______
Allergies: ______
______
Emergency Contact:______
7985 Knight Road. Suite B Gainesville, Georgia 30506
770-781-4899 office 770-781-4094 fax
Volunteer/Staff Information Form and Health History
PHOTO RELEASE:
I consent to and authorize the use and reproduction by Finding Faith Inc, of any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, and exhibitions, or for any other use for the benefit of the program.
Signature:______Date:______
Please use this space to describe your availability.______
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______
______
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Is this volunteer experience to fulfill requirements for school/other? ______
I understand that the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this hippotherapy program.
Signature:______Date:______
If the applicant is a minor, I ______, legal guardian of the applicant minor, attest to the validity of the contents of this application and give permission for my child to participate as a volunteer in the hippotherapy program.
Signature:______Date:______
7985 Knight Road. Gainesville, Georgia 30506
770-781-4899 office 770-781-4094 fax
Volunteer Confidentiality Statement
Medical records are confidential for the protection of patients, families, employees, therapists, and students/interns. Confidential information includes any information that a student or intern hears or sees while conducting evaluation, research, or educational activities at Finding Faith. Patient privacy is to be respected at all times. Breach of confidence is cause for immediate termination of the individual's educational or internship affiliation with Finding Faith.
My signature below indicates the following:
1. I agree not to repeat or discuss, with any unauthorized individuals, confidential information, which I may see or hear in conducting evaluation, research, or educational activities while at Finding Faith.
2. I agree not to obtain or distribute any originals or copies of Finding Faith' and/or its facilities' documents that are considered confidential or part of a patient's medical record.
3. I understand that breach of confidence is cause for immediate termination of my educational or internship affiliation with Finding Faith.
4. I understand that unauthorized release of confidential information may subject me to civil liability under the provisions of state and federal laws.
Name (Print): ______
School (Print): ______
Signature:______
Date:______
7985 Knight Road Suite B. Gainesville, Georgia 30506
770-781-4899 office 770-781-4094 fax
Liability Release
______, (volunteer’s name) would like to participate in the Finding Faith Inc program. I acknowledge the risks and potential for risks of horseback riding and working with horses. However, I feel that the possible benefit of the volunteer experience is greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Finding Faith, Inc, it’s officers, instructors, therapists, volunteers, employees and the owners of the horses or facilities being utilized for the program or any other entity associated with the program for any and all injuries and/or losses I may sustain while participating in the Finding Faith, LLC hippotherapy program.
WARNING
Under Georgia law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Chapter 12 of Title 4 of the Official Code of Georgia Annotated.
Signature:______Date:______
If the volunteer is a minor, I ______, legal guardian of the volunteer minor, have read the above stated warning and liability waiver and agree to it’s terms and conditions.
Signature: ______Date:______
Walker Therapy Center / Finding Faith
CONFIDENTIALITY AGREEMENT
And Electronic Communication, Internet, and Email Policy
The Practice is dedicated to providing its employees and volunteers with the most technologically advanced tools to perform their job functions. Along with this goal comes the need for restrictions for appropriate usage of the technology. Every employee and volunteer must follow the procedures below regarding appropriate usage of the Internet and e-mail applications.
I understand that Walker Therapy Center, P.C., hereafter referred to as WTC or the practice, has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their health information. Additionally, WTC must assure the confidentiality of its human resources, payroll, research, computer systems, and management information (collectively “Confidential Information”).
In the course of my employment/assignment at WTC, I understand that I must sign and comply with this agreement in order to get authorization for access to any of WTC’s confidential information.
I further understand that I must sign and comply with this agreement in order to get authorization for access to any of WTC’s health care confidential information.
I will comply with the HIPAA privacy act and any security or privacy policy promulgated by WTC to protect the security and privacy of confidential information.
I will not disclose or discuss any confidential information with others, including family or friends, who do not have a need to know it. In addition, I understand that my personal access code, user ID, and passwords used to access computer systems are also an integral aspect of this confidential information.
I will not access or view any confidential information, or utilize equipment or supplies, other than what is required to do my job. If I have any question about whether access to certain information is required for me to do my job, I will immediately ask the owner for clarification.
I will not discuss confidential information where others can overhear the conversation, for example; in hallways, on the elevator, at the front desk, on public transportation, at restaurants, or at social events. It is not acceptable to discuss confidential information in public areas even if a patient’s name is not used. Such a discussion may raise doubts among patients and visitors about our respect for their privacy.
I will not make inquiries about confidential information for other personnel or any individual or party that does not have proper authorization to access such confidential information. For example, it is not acceptable to use your logon and passwords to access information for any persons that are not a patient of the practice. This includes insurance company’s websites, hospital sites, lab result sites, etc.
I will not willingly inform another person of my computer password or knowingly use another person’s computer password instead of my own, for any reason, unless it has been approved by the Privacy Official or the Owner.
I will log off any computer terminal prior to leaving it unattended IN ALL PATIENT CARE AREAS. If my terminal has been approved by the owner as a non-patient care area I am allowed to leave my terminal without logging off for short periods of time.
Employees and volunteers will follow WTC’s policy on changing passwords as appropriate, and/or maintaining password protected screensavers as directed.
I will immediately report to the owner any activity, by any person, including myself, that is a violation of the agreement or of any WTC information security or privacy policy.
I understand the computers, phones, pagers, and other electronic communication devices provided to me by WTC are the property of WTC and are provided to facilitate the effective and efficient conduct of practice business. I understand that employees are permitted access to the Internet and electronic communication systems to assist in the performance of their jobs. This includes but is not limited to, computers, cellular phones, text pagers, e-mail, and instant messaging.
I will not access or view any internet sites which may be considered inappropriate. I understand that personal use of electronic equipment is strictly prohibited if it interferes with my productivity or work performance, or any other employee’s productivity or work performance, or if it adversely affects the efficient operation of the practice’s information systems. Strictly prohibited activities include accessing, downloading, printing, or storing information with sexually explicit content; downloading or transmitting threatening, offensive, discriminatory, or otherwise unlawful messages or images; downloading or installing computer programs or software for non-practice use; sending electronic communication using another’s identity; and any other activity designated as prohibited by the practice.
I will not abuse my access to the WTC computers, phones, pagers, and other electronic communication devices, for personal use, during working hours.
I understand, WTC has a right to monitor and or record any and all aspects of the information systems, including, but not limited to, phone calls, Internet usage, IM, chat groups, listservs, and e-mail. Any activity is subject to be audited and/or restricted at any time. Inappropriate activity may result in disciplinary action, up to and including termination of employment or volunteer status and/or suspension and loss of privileges, as well as legal liability. I will direct any questions I have about WTC’s policy to the Owner.
I understand that e-mail communication between employees and patients and/or patients or between employee to employee regarding healthcare and treatment modalities is prohibited on the internet, unless you are using our practice’s secure email system.
I understand that if I am given access to outside websites (e.g. hospitals, and insurance companies) under an individual and/ or group log on code and password I am accessing the information as an employee of WTC, P.C. and am bound to all terms under this confidentiality agreement.
I understand that any Confidential Information that I access or view at WTC does not belong to me.
I will not make any unauthorized transmission, copies, inquiries, disclosures, modifications, or purging of confidential information. Such unauthorized include, but are not limited to, removing and/or transferring confidential information to unauthorized locations.
Upon termination of my employment or volunteer status, I will immediately return any property, documents or other media containing confidential information to WTC. (Ex’s: keys, security cards)
I understand that violation of this agreement may result in disciplinary action, up to and including termination of employment or volunteer status and/or suspension and loss of privileges, as well as legal liability.
I agree that my obligations under this agreement will continue after the termination of my employment.
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Volunteer Printed Name
______
Volunteer SignatureDate
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