REMOTE AREA MEDICAL
Wise RAM Volunteer Registration Form
Registration
Deadline: July 1, 2010
(Registrations may not be accepted after this date)
Date(s):
July 23-25, 2010 Location:
Wise, Virginia Country:
USA
NAME:
Phone (primary):
______________________________
ADDRESS:
EMAIL: _______________________________________
PROFESSION: _________________________________
JOB ASSIGNMENT (CIRCLE
ONE):
Medical:
MD DO FNP PA Triage:
RN LPN EMT Pharmacy: Pharmacist
Certified Pharmacy Tech
Vision:
Ophthalmologist Optician
Optometrist Optical Tech
Support OTHER: ___________________
Dental:
Dentist
Dental Hygienist Dental
Assistant Dental Support OTHER:
___________________
Patient Registration
Volunteer Registration Patient
Escort Security Grounds
Parking Other:
________________
DATES/SHIFTS FOR WHICH
YOU ARE VOLUNTEERING (Preference is given to
volunteers who can work all day) Circle all that
apply:
Friday, July 23: 6am
– 12 noon 12 noon – 6pm Saturday,
July 24: 6am – 12 noon 12 noon – 6pm
Sunday, July 25: 6am – 12 noon
Volunteers are
needed many days prior to RAM to mow, weed-eat,
spruce up the Fairgrounds, and set-up for the
event. Volunteers to assist with parking are
needed early each morning of the event.
Security personnel are needed throughout the
event. General Volunteers are needed Thursday
afternoon, Sunday afternoon, and Monday
following RAM as well. Volunteers are needed for
patient registration at the Wise County Health
Department on Thursday, Friday, and Saturday
during RAM, as well as during the following week
to help with patient counts, verifying records,
etc. If you are interested in any of the duties
mentioned above, please indicate dates, times,
and duties for which you are volunteering in the
space below:
____________________________________________________________________________________________________________
Compliance Statement
I
hereby attest that my license/certificate is not
restricted, suspended or revoked nor is any such
action pending, pursuant to disciplinary proceedings
in any jurisdiction. A COPY OF MY CURRENT STATE
LICENSE OR CERTIFICATE AND DEA# (where applicable)
IS ATTACHED HERETO. If functioning as a Nurse
Practitioner or Physician’s Assistant at RAM, the
supervising physician of record must also be
present.
Confidentiality Statement
I
understand that while I am participating as a
registered volunteer at the Remote Area Medical
Clinic, it is mandatory that I maintain complete
privacy and confidentiality of all patients. This
pertains to all present and future digital, written
and verbal communications referring to any Remote
Area Medical Clinic patient. I also understand that
unless I am obtaining information strictly for
patient registration, I DO NOT ASK a patient
any questions regarding medical insurance coverage,
Medicaid, or Medicare. Further I agree not to
photograph or record patients while at RAM. With my
signature on the line below, I acknowledge that I
have read, understand, and agree to adhere to this
policy of confidentiality for the Remote Area
Medical Clinic.
Release and Indemnification
I hereby
release and indemnify Remote Area Medical, a
non-profit organization, and all its respective
officers, directors, agents, contractors, heirs,
successors and assigns, from prosecution or
presentation of any claim for bodily injury or death
or for property loss or damage incurred in
connection with this Remote Area Medical expedition
or related activities.
Printed Name
Signature
_______________________________________
State(s) of Licensure(s)/Certification(s)
Remote Area Medical is
a 501(c)(3) medical relief charity located at 1834
Beech Street, Knoxville, TN 37920, 423-579-1530
Medical/Licensed
Health Professional Volunteers (doctors, nurses,
therapists, pharmacists, etc):
Please return form and copy of current license (if
applicable) to:
Wendy Welch, 1 College Avenue, Wise, VA 24293 or FAX to
276-328-0295. Questions may be directed to
medvols@uvawise.edu or Wendy Welch at (276)
376-4882.
Non-Medical
General Volunteers:
Please return form to:
Stacey Ely, Mountain States Health Alliance, 32
6th Street, Bristol, TN 37620 or FAX to:
423-764-1172. Questions may be directed to
ramvolunteers@msha.com or Stacey Ely at (423)
764-1137 or Bo Wilkes at (423) 431-1002.
