Volunteer Interest Form

Name______

Address______

City/State/Zip______

Home Phone ______

Cell Phone______

Email Address______

How did you learn about The Victory Center?______
______
What day(s) and time(s) of day are you generally available to volunteer?

______

What special skills are you willing to share with us (i.e. computer skills, public speaking, baking, etc.)? ______

Is there a specific task you’d like to perform for The Victory Center?

Staff notes:

______

Please take a moment to look over the enclosed list of volunteer opportunities and check any that look interesting to you. Thank you for your interest in volunteering at The Victory Center. Please note that all volunteers will be asked to sign a Statement of Confidentiality form and will be required to keep all information pertaining to participants confidential at all times.

VOLUNTEER CATEGORIES

 Phone/Desk
answering phones, making appointments, organizing therapist folders, making reminder calls,greeting participants, offering them coffee, tea, or water, sometimes escorting them to their therapist,engaging in occasional chit-chat as the participant is so inclined, answering any questions participants may have, and other miscellaneous tasks related to this area

 Office Tasks
miscellaneous tasks such as putting participant packets together, preparing mailings, filing, faxing, copying, folding, etc.

Computer
typing donor letters & envelopes, working with databases & mail merges, and other computer tasks as needed, etc.

 Health Fair Ambassador
staffing TVC display at health fairs and other local events, answering general questions about TVC and handing out materials, making sure needed info gets to and from event
Fundraising/Committees
willing to serve on a committee to help fundraising events, and/or possibly (if you so desire) chairing an event

____ The Victory Center’s Signature Luncheon & Fashion Show

____ Treasures Event (food, wine & beer tasting along with art auctions)

____ Celebrity Wait Night

Wig Bank

Assisting those women in finding wig style that are experiencing hair loss due to cancer treatment

 Follow-up calls
make calls to new volunteers and encourage them, sign them up for something, involve them, also make calls to participants as needed.

 Deliveries
delivering brochures to doctors' offices and medical offices around town, other deliveries as needed.

Special Projects

making improvements around The Victory Center, painting offices, etc.

Recycling
we are in need of individuals who can collect the center’s recycling and take it to a nearby recycling center every other week (two times a month).

PURPOSE

To assure that the participant’s right to privacy is protected by specifying the protocol regarding confidentiality of the personal information and release of that information, as necessary.

POLICY

The VictoryCenter, its personnel, therapists, and volunteers will maintain, as confidential, all records and information related to participants. No information will be released without prior written authorization by the participant or his/her representative.

PROCEDURE

Upon hire and annually, all personnel will sign a Confidentiality Statement (see attachment)

  1. Only personnel involved in the care or the supervision of care with a participant will have access to a participant’s records.
  1. Participants will not be discussed by any personnel outside of the context of professional conversation regarding participant’s condition and care.
  1. Records will not be released to any third-party without a written authorization from the participant.
  1. Acknowledgements of participation may be sent to the participant’s referral source. (i.e. physician)
  1. An agreement and consent form, including authorization to release information, will be signed by the participant upon entry to any program at The Victory Center.
  1. All VictoryCenter personnel and volunteers will be asked to sign a confidentiality statement during orientation.
  1. Any breach in confidentiality on the part of VictoryCenter personnel or volunteer is grounds for possible termination.
  1. Verbal communication regarding a participant may from time to time be necessary. This communication must be treated with the same concern for the best interests of the participant as written material. Spoken communication in which the participant is individually identified must be documented in the participant’s records. Casual conversation or other remarks about participants should be avoided at all times.

THE VICTORYCENTER

CONFIDENTIALITY AND

RELEASE OF INFORMATON STATEMENT

I have been informed of and understand The Victory Center’s policies regarding the confidentiality of participant’s records and other information. I realize my obligation, as a volunteer, to comply with these policies.

______

DateSignature