Bloom Pediatrics
Nature. Nurture. Bloom.
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Volunteer Application

Volunteer with us!

 

Volunteer with us

If you would like to volunteer with us, please complete the application below. Be sure to read our volunteer guidelines carefully before submitting. Since we are a unique and small family-centered private practice, we require an interview or trial day prior to accepting volunteers for an ongoing basis.

VOLUNTEER APPLICATION
Volunteer guidelines *
Personal information
Name *
Name
Phone *
Phone
School and/or employer information
Actual or anticipated.
If you have a LinkedIn profile, please include it here.
http://
Additional information
Schedule and availability *
Please check when you would be available to volunteer with us. Check all options that apply. Keep in mind that our site requires that volunteers maintain a consistent weekly schedule in 3-4 hour blocks of time.
CONFIDENTIALITY STATEMENT
As a volunteer at Bloom Pediatrics, you may have access to confidential information. The purpose of this agreement is to help you understand your obligations regarding confidential information. Confidential information is protected by Federal and State laws, regulations, including HIPAA, the Joint Commission on Accreditation of Healthcare Organizations standards, and Bloom Pediatrics policies. The intent of these laws, regulations, standards, and policies is to ensure that confidential information will remain confidential – that is, that it will be used only as necessary to accomplish the purpose for which it is needed. As a volunteer, you are required to conduct yourself in strict conformance with applicable laws, standards, regulations, and Bloom Pediatrics polices governing confidential information. Your principal obligations in this area are explained below. You are required to read and to abide by these rules. Anyone who violates any of these rules will be subject to discipline, which might include, but is not limited to, termination of any affiliation or relationship with Bloom Pediatrics. In addition, violation of these rules may lead to civil and criminal penalties under HIPAA and potentially other legal action.
Confidentiality agreement *
All boxes must be checked in order to volunteer with us.
Practical privacy guidelines *
All boxes must be checked in order to volunteer with us.
Electronic signature agreement *
Today's date *
Today's date