Abbreviated Title
Example: Mr., Ms., Dr., Hon., Mx.
Professional Abbreviations
Example: DDS, MD, PhD
Name on Badge
List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam
Contact Phone with Area Code
Phone Type
If possible, we would like to text you with occasional reminders and pertinent updates.
Mailing Address Line 1
Include apartment, suite or box number, if applicable.
State
Email Address
We recommend an email address unique to the registered volunteer instead of a shared
office address or the personal address of a group leader for all group members. We will send personalized scheduling
correspondence to this address.
User Name
Establish your unique User Name. You may use your email address as your
User Name unless another registered volunteer will be receiving correspondence at that same address.
Password
Used to recall your information when you visit this site again so you can make
changes and/or select additional volunteer opportunities. Your password must be at least 8 characters and contain at least one letter and one number. It may not contain the characters < ' & * # .
Required Age
I will be at least 16 years of age when I volunteer
For legal reasons these are the age restrictions for volunteering.
T-Shirt Size
T-Shirt style is adult unisex. Note that t-shirts may not be provided at all events.
Language Fluency (other than English)
Select all that apply
Hold down the control key to select more than one language.
Hold down the control key and click on a selected language to de-select it.
Skills
Do you have any other skills or interests that you'd like to share that may be beneficial to our clinics? If so, please list them. If not, please mark "N/A".
Company / Organization
Optional, but helpful to know especially if you're coming with an office or team.
My company has a matching program
Please indicate if your employer matches your donated time with a financial donation
to the non-profit where you volunteer.
Description of Company Match
Describe the program requirements and let us know how we can help - provide information
for anyone we must contact and/or list any documentation you might need etc.
Event Volunteer Area
Select the area appropriate to your profession / classification.
Profession / Classification
License Number
Use this field to enter your license, registration or certification number, whatever type is relative to your profession.
Prof. Liability Insurance Carrier
Professional Liability Insurance: I agree to carry professional liability insurance at all times that I provide volunteer services as part of California CareForce's (hereinafter “Nonprofit”) community service programs. I understand that Nonprofit rules prohibit my participation in providing volunteer medical/dental services without said insurance. I agree to notify Nonprofit immediately in the event that my professional liability insurance lapses or terminates. I acknowledge that Nonprofit does not carry professional liability insurance, and will not indemnify or defend me with respect to claims arising out of medical or dental care received by a patient at Nonprofit’s community service programs. I further agree to immediately inform Nonprofit in writing of any disciplinary or licensure actions, whether with or without merit, at any time I may be providing volunteer medical or dental services as part of Nonprofit’s community service programs. I further agree to hold harmless and defend Nonprofit with respect to any and all claims or actions brought based on and/or alleging medical/dental negligence, malfeasance or willful misconduct on my part.
State of Licensure
All licensed healthcare professionals participating in a California CareForce clinic as a "Professional Volunteer" MUST BE licensed in the state of California.
License Comment
List additional information we should know. Examples: You selected Other Professional - indicate
field/specialty. Your license will renew before the clinic. You are licensed in a second field - provide license details.
We welcome student participation, however student spaces are limited and students may be restricted in their type of involvement in direct patient care. The criteria for student participation also varies by discipline.
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Field of Study / Degree Program
Onsite Faculty Supervisor
Limit event list by state?
Event
To sign up for multiple events, complete your entire registration and assignment selections for the first event and click SAVE AND SUBMIT. Then come back to choose a second event and make assignment selections. Again, click SAVE AND SUBMIT to ensure its complete.
Event Location
More detailed directions will be available prior to your arrival.
Event Email
Please add this information to your safe senders/callers list.
For each date, select either a specific assignment or "Not Attending This Day." If your preferred assignment is full, a waiting list option may be shown. If you choose to be on the waiting list for your preferred assignment (i.e. Patient Registration) you will be given the option to select an alternate assignment (i.e. Volunteer Registration). If an opening becomes available in your preferred assignment and you are moved from the waiting list, you will receive an email notice of this change. If you also selected an alternate assignment, you will be automatically canceled from the alternate assignment.
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Release and Liability AgreementThis Release and Liability Agreement releases California CareForce (hereinafter “Nonprofit”), a nonprofit organization existing under the laws of the State of California, and each of its directors, officers, employees, and agents, from liability as set forth below, and clarifies the responsibilities of the parties related to Volunteer’s participation in Nonprofit’s community service programs.
The Volunteer desires to provide volunteer services for Nonprofit and engage in activities related to serving as a volunteer. Volunteer understands that the scope of Volunteer’s relationship with Nonprofit is limited to a volunteer position and that no compensation is to be expected in return for services provided by Volunteer, that Nonprofit will not provide any benefits traditionally associated with employment to Volunteer, and that Volunteer is responsible for his/her/its own insurance coverage in the event of a personal injury or illness to the Volunteer or any other person as a result of Volunteer’s services to Nonprofit.
1. Waiver and Release: I, the Volunteer, release and forever discharge and hold harmless Nonprofit and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the services I provide to patients pursuant to Nonprofit’s community service programs, except to the extent that said liability, claims or demands are the result of the negligent or willful misconduct of the Nonprofit. I understand and acknowledge that this Release discharges Nonprofit from any liability or claim that I may have against Nonprofit with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to Nonprofit or occurring while I am providing volunteer services.
2. Insurance: I understand that Nonprofit does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to, medical, health, disability benefits, or insurance of any nature in the event of my illness, death, or damage to my property. I expressly waive any such claim for compensation or liability on the part of Nonprofit beyond what may be offered freely by Nonprofit in the event of such injury or medical expenses incurred by me.
3. Medical Treatment: I hereby Release and forever discharge Nonprofit from any claim whatsoever which arises and may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with Nonprofit.
4. Assumption of Risk: I understand that the services I provide to Nonprofit may include activities that may be hazardous to me including, but not limited to, inherently dangerous activities. As a volunteer, I hereby expressly assume the risk of injury or harm from these activities and release Nonprofit from all liability for injury, illness, death, or property damage resulting from the services I provide as a volunteer or occurring while I am providing volunteer services.
5. Photographic Release: I grant and convey to Nonprofit all right, title, and interests in any and all photographs, images, video recordings, or audio recordings, of me or my likeness or voice made by Nonprofit in connection with my providing volunteer services to Nonprofit.
6. Miscellaneous: As a volunteer, I expressly agree that this Release and Agreement is intended to be as broad and inclusive as permitted by the laws of the State of California and that this Release shall be governed by and interpreted in accordance with the laws of the State of California. I agree that in the event that any clause or provision of this Release and Agreement is deemed invalid, the enforceability of the remaining provisions of this Release and Agreement shall not be affected.
Confidentiality Agreement Volunteers/Staff
I, the undersigned, acknowledge that during the course of my voluntary participation or performance of duties at California CareForce Clinics, that I may receive access to confidential information of the organization and/or patients that is prohibited from disclosure to others.
“Confidential Information” means information provided by California CareForce or the patients served at each California CareForce clinic that is not commonly available to the general public, or is required by law or regulation to be protected from disclosure to third parties not considered part of the California CareForce “workforce” as that term is defined by federal and state health information privacy regulations such as the Health Information Portability and Accountability Act. Confidential information includes information contained in patient medical records and any other health information which identifies a patient; quality assurance, research or peer review information; and information concerning the California CareForce employees, services or business operations. Such information can be acquired by any means and in any form, written, spoken or electronic.
I agree not to share, disclose or discuss Confidential Information with anyone who does not have a legitimate interest in such information. I agree not to take picture of videos of patients, their family members or other volunteers unless directed to do so by a California CareForce employee. I will abide by California CareForce policies and procedures concerning the use or disclosure of Confidential Information and I will contact a California CareForce staff person if I have any questions regarding these policies and procedures.
I will maintain and protect the privacy of the California CareForce employees, volunteers and patients in my use and disclosure of Confidential Information, and I will not misuse or be careless with such information. I understand that any violation of this Agreement or California CareForce policies related to access, use or disclosure of Confidential Information may result in significant legal ramifications for which I will be solely responsible with respect to this Agreement.
I acknowledge that I have reviewed all the information above. I understand that compliance with the principles, policies and procedures expressed above is a condition of my participation and continued presence at California CareForce clinics.
By signing below I am indicating that I have read this agreement and fully understand its terms and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me, and intend my signature to be a complete and unconditional release of all liability.
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