Volunteer Application Before completing the volunteer application please read through our Volunteer Expectations. Mission * Mission Statement: The Refuge Clinic’s purpose is to restore health and value to the community through the unconditional love of Jesus Christ. Vision Statement: We believe Jesus Christ came to bring ultimate healing for all and that it is our responsibility as the Church to act as the hands and feet of Christ, and to compassionately serve others with love and respect guiding each interaction. The Refuge Clinic is to be a channel through which God can extend His love, grace, and healing to the community. It is our intent to be a demonstration of God in the midst of those we serve by placing value on every life. Our goal is to provide care with a holistic approach that ministers to the physical, mental and spiritual aspects of each person we serve. By signing below, I acknowledge that I will respect and adhere to the mission and principles of the Refuge Clinic. I recognize that refusal to uphold the vision and purpose could result in my dismissal as a volunteer for the Refuge Clinic. Do you agree with the above statements? Yes No Serving * We are blessed with the possible opportunity to work with you in ministry and outreach to our community. This organization is unable to provide services without those who are willing to volunteer their expertise and time, so we are grateful for your desire to serve. Due to the nature of our ministry and our focus to build relationships with our patients, we ask that volunteers serve a minimum of one clinic per month. I have read this statement and agree that I am able to commit to volunteer a minimum of once per month. Yes No Volunteer Expectations * I have also read, understand, and agree with the Volunteer Expectations as outlined on the Refuge Clinic website. Yes No Information First Name * Last Name * Middle Name * Gender Male Female Date of Birth * MM DD YYYY Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Previous Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact * Name, Phone, Relationship Authorize * I, the undersigned applicant (also known as “consumer”), authorize Refuge Ministries, Inc., without reservation, through its independent contractor, Shield Screening, or any third party contacted by this organization, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history / records; and the state sex offender records. I further authorize ongoing procurement of the above-mentioned information, reports and records at any time during my volunteerism or in the course of considering me for a volunteer position. I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my written request to Refuge Ministries, Inc., if such a request is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act. * Yes No Education High School and Graduation Year * College/University, Graduation Year, Field of Study * Work History Current Employer, Title/position and duties, address and length of employment (please list current/previous employment for at least the last 12 months) * Previous Volunteer Experience (organization, length of service, duties) * Certifications/Awards Text Do you speak any other languages? References (Please provide 2 references and include name, address, relationship, phone number, and email) * Have you been baptized by immersion? * Yes No If yes, when? * Do you currently have a church that you attend? * Yes No If yes, where? * Are you currently volunteering anywhere? * Yes No If yes, where? (Please indicate if you are a current Refuge Clinic volunteer) Here at The Refuge, we value not only the personal testimonies of our patients but of our volunteers as well! * Please give us a brief description of how you came to know Christ as Lord and Savior. Volunteer Opportunies Please check how you are interested in helping. * (check all that apply) Physician/Nurse Practitioner/PA-C Dental Hygienist Nurse I am a student Counselor Dietician/Nutritional counselor Interpreter Dentist Pharmacist Dental Assistant Nurse Assistant Front Desk Patient Advocate/Social Worker Transporter for patients Assessment Team Have you received the Hepatitis B vaccine (series of 3)? * Yes No Professional License Number and date of expiration (if applicable) Do you currently have privileges at any hospitals? * Yes No Have your privileges ever been denied, suspended, revoked, or refused for renewal, or is there a pending case? * Yes No Has there been any restriction on your state licensure? * Yes No Have you been involved in any liability action? * Yes No Have you ever been charged or convicted of a misdemeanor or felony? * Yes No The Refuge Clinic supports the biblical view that sex is God’s gift to be enjoyed exclusively in the context of a marriage between one man and one woman. Are you currently engaged in premarital sexual relationships, homosexual sexual activity, and/or other sexual activities outside of a heterosexual marriage relationship? * Yes No The Refuge Clinic has a policy against volunteers using illegal drugs, abusing prescription medication and/or alcohol. Do you have any habits or tendencies that will undermine your ability to follow this policy? * Yes No Do you have any concerns in your life that would impact your involvement or commitment in your ministry here at The Refuge Clinic? Yes No If you answered yes to any of the previous questions, please explain and add additional information. * If you answered no, please type "N/A" in the box below. I hereby attest that I have answered these questions honestly and to the best of my knowledge. I also recognize that withholding information or future charges could result in my dismissal as a volunteer for the Refuge Clinic. * Yes No Which clinic and days are you available to serve * (feel free to check multiple times) Fayette : Mondays 9:00 a.m. - 12:00 p.m. Fayette : Mondays 1:00 p.m. - 4:00 p.m. Fayette : Tuesdays 9:00 a.m. - 12:00 p.m. Fayette : Tuesdays 1:00 p.m. - 4:00 p.m. Fayette : Wednesdays 9:00 a.m. - 12:00 p.m. Fayette : Wednesdays 1:00 p.m. - 4:00 p.m. Fayette : Thursdays 9:00 a.m. - 12:00 p.m. Fayette : Thursdays 1:00 p.m. - 4:00 p.m. Fayette : Fridays 9:00 a.m. - 12:00 p.m. Fayette : Fridays 1:00 p.m. - 4:00 p.m. Jessamine : Mondays 5:30 p.m. - 8:30 p.m. Jessamine : Tuesdays 5:30 p.m. - 8:30 p.m. Jessamine : Wednesdays 5:30 p.m. - 8:30 p.m. Jessamine : Thursdays 5:30 p.m. - 8:30 p.m. NonDisclosure Agreement * Please read all sections of this confidentiality agreement. If you have any questions regarding this agreement, please ask before signing. You are entitled to receive a copy of this agreement for your own records. DISCLOSURE OF PATIENT/PROVIDER INFORMATION: I, the employee/volunteer, recognize and acknowledge that the services Refuge Ministries provides for its patients are confidential and that to enable the medical clinic to perform those services, its patients/providers furnish the clinic staff/volunteers confidential information concerning their affairs; that the goodwill of the clinic depends, among other things, upon its keeping such services and information confidential; and that by reason of their duties, the employee/ volunteer may come into possession of information concerning the services performed by the clinic for its patients and providers even though the employee/volunteer does not take direct part in, or furnish the actual services performed for those patients and providers. I accordingly agree that, except as directed by the clinic, I will not, at any time during or after my volunteer commitment /employment with Refuge Ministries, disclose any such services or information to any person whatsoever, or permit any person whatsoever to examine or make copies of any reports or other documents prepared by me or coming into my possession or under my control, that have in any way to do with the patients or providers of the clinic. I recognize that the disclosure of information by me may give rise to irreparable injury to the client or clinic, or to the owner of such information, and that accordingly, the clinic or the owner of such information may seek any legal remedies against me that may be available. I agree that at all times, I will comply with all security regulations in effect from time to time at the clinic premises and externally for all materials belonging to the clinic. I have read and understand and agree to all of the above sections of this agreement. Yes No Thank you for the completion of your online application! I look forward to connecting with you in the next few business days with next steps. Should you have any immediate questions, please let me know! Ellen Hughes Volunteer Coordinator ehughes@refugeclinic.org Your application has been submitted.Thank you!
