CONTACT INFORMATION

Full name: Today’s date:

Mailing address (Address (P.O. Box if applies) / City, State, ZIP):

Home address (if different):

Home phone:      Work phone:      Cell Phone:

Fax: Pager:   Email:

May we call you at work if necessary? Yes No      

What is the best time to reach you?  AM PM

What is the best way to contact to you? 

Are there times or places we should not call?

BACKGROUND INFORMATION

Employer:   Occupation:

Normal work hours: Are you a student? Yes No

If so, where?

and what field of study?

How did you hear about or come to the BESTD clinic?

EXPERIENCE

Do you presently volunteer at another agency(ies)?  Yes No   

If so, where? 

Please list the names and years of agencies where you have

volunteered in the past:

1.) When:    Agency:

2.) When:    Agency:

3.) When:    Agency:

3.) When:    Agency:

3.) When:    Agency:

Degree programs, field of study, expertise, talents, skills or interests that you could share with BESTD:

Are you fluent in languages other than English? Yes No

If Yes, which ones?

What is your main reason for wanting to volunteer at BESTD?

Other information you would like to provide:

EXPERIENCE (For health care professionals only):

What medical training/degrees do you have:

Licenses you hold:

Have you completed OSHA blood borne pathogens training?  Yes No

Last year that you had blood borne pathogens training:

Have you had a hepatitis A & B vaccination?  Yes No        

Recent TB tests?   Yes No

AVAILABILITY

Best times for me to volunteer at present are as follows:

Please enter available DAYS along with HOURS:

Understand that as a BESTD volunteer you will be expected to adhere to the

following guidelines and serve guided by the BESTD volunteer code.

BESTD Volunteer Guidelines

1. To make a commitment to volunteer regularly (a minimum of every other week unless mutually agreed otherwise) for at least 6 months.

2. To be realistic in signing up for volunteer staff slots.

3. To follow the time commitments I make.  If a schedule conflict arises, to attempt to find another volunteer

            to complete the commitment I have made.  In an emergency, to notify the appropriate person(s) at BESTD

            clinic as soon as possible, that I cannot complete the task for which I have volunteered.

4. To help maintain the decorum and atmosphere in the clinic or at outreaches consistent with what clients have a

            right to expect of a professional health care agency.

5. To request and receive training consistent with completing all of my assignments as professionally and fully as I can.

6. To respect the anonymity/confidentiality of each client I serve or whom I see at the clinic or any of its programs.

7. To both give and receive respect and acceptance for my colleagues and clients, even though we may have differences

            in religious, moral, social, affectation or generational areas.

BESTD Volunteer Code

As a BESTD volunteer, I acknowledge that I am subject to a code of ethics and commitment similar to that which binds professionals in

the health care field.  Like them, I assume certain responsibilities and expect to be accountable for what I do or am expected to do.

I will keep anonymous matters anonymous and confidential matters confidential.  I understand that all BESTD clients must expect that

their visit, service and records are not discussed or shared outside the clinic environment.  I interpret “voluntary” to mean that I

have agreed to work without compensation in money, but having been accepted as a BESTD staff member I expect to do the tasks that

I am assigned as well, if not better, than those who are paid.  I believe that my attitude to my BESTD work must be professional. 

I will honor the time and task commitments I make and fulfill them as one of the priorities of my life.  If illness or an emergency

prevent me from honoring my commitment, I will either attempt to find someone to replace me or notify the Clinic with the longest

possible lead-time.  I will not knowingly allow client service to be less than adequate or my volunteer colleagues to have to

double up due to my negligence, irresponsibility or lack of commitment.

While I recognize that I have my own life style, values, morals and religious convictions, I will also respect the same in other volunteers

and clients, even though we may differ in any or all of these areas.  I expect to be treated by my colleagues and by clients with dignity,

openness and respect and will offer the same to them.  All of this flows from my belief that I have a deep responsibility and commitment

to my volunteer work, to the BESTD Clinic mission, to those who direct it, to my colleagues, to those for whom we provide service and to

the public.  I have read and given careful consideration to this application, the clinic’s guidelines and the BESTD volunteer code and I

request consideration for services as a BESTD volunteer.

Online Submission Agreement

I hereby acknowledge and understand my information will be sent with reasonable security to the BESTD Clinic via the Internet.  With my electronic signature below, I can attest that the signature is my own, and understand that information collected can be used to verify

such facts.  I also agree to the collection of this information such as time of day, etc. 

Signed (type full name): 

Today's Date: 

At this point, you may wish to print this screen for your records before submitting your application.