Volunteer Application

Step 1 of 6

Step 1: Reading Materials

Please review the packet below and indicate that you have read the content before proceeding to the application. We will contact you soon after receiving your completed application to follow up regarding volunteer positions and training opportunities for the programs or topics that interest you. Volunteer Application Reading Packet

Volunteer Agreement / Code of Ethics

Checking this box will act as your electronic signature(Required)

I agree

As a volunteer for the Atlanta Regional Commission, I realize that I am subject to a code of ethics similar to that which binds others in the field in which I work. Like them, I assume certain responsibilities and expect to account for what I do in terms of what I am expected to do. I recognize and adhere to the following points of volunteer ethics and as a volunteer will endeavor to:

1. Perform activities as assigned

2. Recognize the boundaries of my level of training and skills and consult with appropriate staff when needed.

3. Participate in efforts to maintain and promote the integrity and credibility of the program

4. Provide unbiased information provision/counseling as it relates to the various program components.

5. Provide services with respect for human dignity unrestricted by considerations of age, social or economic status, personal characteristics or lifestyle choices

6. Continually safeguard the confidentiality of program participants and not divulge any information obtained in the course of program activities without proper written consent.

7. Make referrals to appropriate agencies as specified in Training Manuals and other procedural guidance provided by the agency.

8. Submit appropriate monthly data and reports on time.

9. Participate in required training and maintain competence in relevant areas.

10. Act in accordance with the standards, policies, and practices of the Atlanta Regional Commission.

11. Avoid any conflict of interest or appearance of a conflict of interest, including financial gain, in the provision of services.

I also declare that I will not sell or endorse any insurance product or any other product or service as a volunteer for the program, and I am not currently employed as an insurance agent. I will do my utmost to uphold this agreement, as I understand the effectiveness and credibility of this program depends, in part, on the way I carry out my responsibilities.

Photo Release Form

Confidentiality Agreement related to HIPAA Regulations

Checking this box will act as your electronic signature

I agree

HIPAA (Health Insurance Portability and Accountability Act of 1996) provides for the safeguarding of each individual’s personal health information (PHI). The federal Department of Health and Human Services has issued a “Privacy Rule” detailing when and how the privacy safeguards apply. The Atlanta Regional Commission (ARC), Aging and Independence Services Group, had adopted privacy policies and procedures to comply with the privacy rule as well as address client confidentiality.

I have received information from ARC to help me better understand how to carry out my responsibilities within ARC volunteer programs. I understand that, based on my duties, access to PHI will be limited only to information, which is the minimum necessary to perform my functions as an ARC volunteer.

In addition, I understand that during my volunteering or other work with ARC, I may see or hear other Confidential Information, including agency operational and financial information, that I must maintain as confidential.

Regardless of the capacity, I understand that I must sign and comply with this Agreement in order to continue to volunteer with ARC.

By signing this Agreement, I understand and agree that:

1. I will keep client information confidential, as highlighted in the Confidentiality and HIPAA Guidelines. Regarding other types of important information, I will keep such information confidential and will only disclose such information if it is required for the performance of my role.

2. I will not discuss any information, either client-related or relating to agency operations, in public areas (even if specifics such as a client’s name are not used), unless that public area is an essential place for the performance of my job.

3. I will keep all security codes and passwords used to access the facility, equipment, or computer systems confidential at all times.

4. I will only access or view client information for that which 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 my supervisor.

5. I will not disclose copy, transmit, modify, or destroy client information or another client confidential information without permission from my supervisor.

6. Once my role with ARC has terminated, I will immediately return all property (e.g., keys, documents, ID badges).

7. Even after my role has terminated, I agree to meet my obligations under this Agreement.

I understand that violation of this Agreement may result in disciplinary action, up to and including termination of my relationship with ARC. This may include civil and criminal legal penalties because of the final Privacy Rule issued by the federal government.

Georgia Bureau of Investigation - Georgia Crime Information Center

Please enter all requested information in full. Your information will be kept confidential, and this form will be deleted after the background check process is complete. Thank you for your cooperation.

Name(Required)

Prefix First Name Middle Name Last Name

Date of birth(Required)

Place of birth(Required)

Gender(Required)

Race(Required)

Eye color(Required)

Hair color(Required)

Weight(Required)

Height(Required)

Country of citizenship(Required)

Non-resident of the USA?(Required)

Yes

No

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email Address(Required)

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