Healthcare Provider Application

Full Name *
Full Name
Date
Date
Phone
Phone
Desired Role
Please state what role you may want to help with
Street Address
Street Address
Have you ever been convicted of any crime including either a felony or a misdemeanor? If yes, please describe when, where, and the nature of the charge (some types of offenses do not necessarily preclude service)
Employer's Address
Employer's Address
Please note your fluency with speaking/writing each language
P(please note the country, type of service, and the dates involved
This is optional, but it lets us know a little more about how you might help
The following is a disclaimer/release of liability. A signed copy is required before engaging in patient care and/or field work with Frontline.
GENERAL RELEASE/DISCLAIMER OF LIABILITY In consideration of Frontline Wellness United arranging a volunteer assignment for me, and with the intention of binding myself, my heirs, legal representatives, successors and assigns, I hereby expressly RELEASE AND FOREVER DISCHARGE Frontline Wellness United, its officers, directors, employees, volunteers, agents, legal representatives, insurers, successors, and assigns from any and all claims, demands, damages, liabilities, and causes of action that I now have or may in the future have, whether known or unknown, of whatsoever nature, relating to or arising out of my selection as a volunteer by, or my service as a volunteer with Frontline Wellness United. This includes, but is expressly not limited to, death, bodily injury, personal injury, property damage, loss or theft of property, economic loss, or any other damage, loss or cost. This document shall be construed according to the laws of the state or states in which service in association with Frontline Wellness United occurs. If a dispute should arise with respect to the meaning of any of the terms of this document, the rule of construction that a document is construed against the party preparing such document shall specifically not be applicable to the interpretation of this document. This General Release represents the entire agreement of the parties hereto and supersedes any and all prior or contemporaneous oral or written understandings, statements, representations or promises. All of the terms hereof are contractual and not mere recitals. I acknowledge that I have carefully read this General Release, know and understand the contents thereof, and that this document was freely and voluntarily executed. I acknowledge that I was given the opportunity to seek independent legal counsel on any and all matters herein before I signed this General Release/Disclaimer of Liability.
Please check this box to indicate that you've read the disclaimer/liability form. *
Code of Conduct: Staff and Volunteers: In working with/volunteering for Frontline Wellness I agree to abide by the operating principles and procedures of the agency throughout the period of my assignment. I will treat all fellow volunteers, staff—and the persons and the communities we serve—with dignity and respect. I agree to conduct myself nonviolently in both speech and action during any period of time I am engaged in my duties as a Frontline Wellness United volunteer, or representing the agency in public or private. *
Please check here if you agree to abide by Frontline's Code of Conduct *