Contact Information
[pic]
|Volunteering Info |
|Where would you like to Volunteer? |
|What would you like to do? |
|How did you hear about volunteering? |
|Your Information |
|Name: |Date: |
|Address: |
|City, State Zip |
|Home phone: |Cell phone: |
|Email address: |
|Any Special Accommodations? |
|Do you have any relatives who are Hillsborough County Staff members? Yes or No |
|If yes, list name and department: |
|Have you graduated from High School or equivalent? Yes or No |
|Education, volunteer and work experience: |
|Emergency Contact info |
|Emergency Contact Name: |
|Relationship: |Cell phone: |
| |
|Hillsborough County requires that a background check on all adult applicants prior to volunteering. All offers are contingent upon passing screening. |
|Fax/Mail application, copy of driver’s license/ID and background check (Attachment 1) to: 813.744.5967 or email to: |
|RamirezD@ and submit your background check via the SSCI link |
|Contact Volunteer Services at (813) 744-5598 or RamirezD@ for more info. |
|Hillsborough County Staff Complete |
|Did you offer applicant a volunteer opportunity? Yes or No |
|Location |Volunteer Opp: |
|Vol Supervisor: |Date: |
INTEREST AND SKILLS CHECKLIST
Please Highlight All That Apply
|Customer |Park Beautification |Parks & Recreation |Mentor Children |Special Events |Environmental |
|Service | | | | | |
| | | | | | |
|Entrance/Park |Work Outdoors |Athletic Coach |Tutor Children |Special Event |Environmental Science |
|Greeter | | | |Planning | |
|Answering |Gardening- |Scorekeeper |Reading to |Special Event |Interpretive Programs |
|Phones |Yard Work | |Children-Storytelling |Set Up, | |
| | | | |Break Down | |
|Basic |Clean Playground Equipment |Field-Play Area |Supervision- |Concessions |Natural History |
|Office Work | |Set Up |Playground | | |
|Afterschool |Safety Checks |Therapeutic |Arts-N-Crafts |Activity/Game |Florida Native Plants & |
|Check In/Out | |Recreation | |Supervision |Animals |
|Nature Center Docent |Simple Maintenance/ |Specialty Camps |Homework Assistance |Fee/Cash |Docent |
| |Custodial |Fishing, Nature, | |Collection | |
| | |Skateboard, | | | |
| | |Fine Arts | | | |
|OTHER | |
| | |
Are You a Seasonal Resident?
If so, which months are you in Florida?
Can we contact you for short term or special project assignments?
Yes or No
|Volunteer for Hillsborough County Parks and Recreation Department |
|Signature: |Print name: |
PLEASE SIGN AND COMPLETE the Acknowledgement of Understanding
and return it with your Registration Form to Volunteer Services.
Workers’ Compensation for Volunteer
Hillsborough County Parks and Recreation Volunteers may be covered for medical benefits in case of accident or injury while volunteering under Hillsborough County’s Workers’ Compensation Program. The insurance is managed by Hillsborough County Risk Management with specific policies and procedures. Please read the following procedures, and sign on the upper portion of this page to indicate that you understand the procedures. If you have questions please call Volunteer Services at (813) 744-5598
Part I – If you sustain an injury, illness, or exposure within the course and scope of your volunteer assignment, you must do the following:
1. Report the injury to your site supervisor or manager immediately to have a claim filed.
2. For all injuries that require more than basic first aid, the injured volunteer should report to the site supervisor or manager to receive instructions and details for care.
VOLUNTEER BENEFITS AND RESPONSIDILITIES
UNDER WORKERS' COMPENSATION
ACKNOWLEDGMENT OF VOLUNTEER'S BENEFITS UNDER WORKERS' COMPENSATION
• A volunteer who sustains an injury, illness or exposure within the course and scope of the volunteer assignment has the right to medical care and pharmaceuticals as described in Florida Statutes, Chapter 440.
• A one-time change of physician is available per injury, upon the volunteer's written request.
• The injured volunteer has the right to assistance from the Division of Workers' Compensation, Employee Assistance Office regarding benefits, concerns or disputes.
• A volunteer has the right to legal representation.
• For further benefits information, volunteers should contact the claims adjuster handling their file or the County's workers' compensation coordinator.
|Please Sign that you understand |
|Signature: |Print name: |
ACKNOWLEDGMENT OF VOLUNTEER RESPONSIBILITIES UNDER WORKERS' COMPENSATION
• A volunteer is required to report to his/her direct supervisor any work related injury, illness or exposure within 30 days of the incident or the claim may be denied.
• An injured volunteer has the responsibility to seek medical treatment for a work related injury or illness from the County's authorized treating physicians.
• It is the injured volunteer's responsibility to provide Volunteer Services with current medical/work status provided by the Workers' Compensation treating physician.
• The injured volunteer has the responsibility of complying with the treating physician's plan of treatment, to include but not limited to working within assigned restrictions, attending doctor and physical therapy appointments.
.
|Please Sign that you understand |
|Signature: |Print name: |
Confidentiality Agreement & Training—Volunteer Workforce
Health Insurance Portability and Accountability Act (HIPAA)
Volunteer Workforce Training
Directions: This form is to be used whenever a person begins service in the volunteer workforce. Its contents should be entered into the HIPAA compliance system by your Privacy Liaison. The form should also be filed with the volunteer’s personnel file.
Read this page carefully and sign the confidentiality statement to confirm that you understand its content and will safeguard protected health information (PHI).
Introduction: As a volunteer workforce member, you are being provided with HIPAA training to assure that you are aware the federal requirements to safeguard PHI.
Hillsborough County wants you to know that:
• Health information about a single person is usually PHI.
• Federal laws require you to safeguard PHI.
• You must cooperate with any official HIPAA investigation.
• PHI may only be used or disclosed as permitted for treatment, payment, and operations (TPO).
• You may use PHI in an emergency to make sure that individual receives medical treatment.
• You must obtain permission or authorization from your supervisor, Privacy Liaison (and Security Liaison for any incidents involving ePHI) or the County Compliance Officer prior to use or disclosure of PHI.
• Permission or authorization must be given by the individual prior to use or disclosure of PHI.
• Individuals have the right to review their medial files, requests amendments, and restrict the use or disclosure of their records.
• Individuals have the right to file complaints if they believe their privacy rights have been violated.
• Those who violate these policies are subject to civil and criminal prosecution.
ACKNOWLEDGMENT OF RESPONSIBILITY
TO MAINTAIN CONFIDENTIALITY OF MEDICAL INFORMATION
The Health Insurance Portability and Accountability Act (HIPAA) requires that the County train all volunteers about the County’s HIPAA policies. HIPAA is a federal law that protects the privacy of an individual’s health information under certain circumstances and makes it confidential. Everyone has to follow the HIPAA laws.
HIPAA mandates that in most instances, health information must be kept confidential unless the person gives specific written authorization or unless compelled by court order or subpoena, or when certain other conditions are met for release of health information.
By virtue of your association with Hillsborough County, you may need to know and, therefore, may be informed of certain health information that is necessary to perform your assigned duties, or may accidentally receive such information. To insure HIPAA laws are not violated, it is our policy not to share any health information about another person without permission from your supervisor or manager.
By signing this form, you acknowledge that you will keep all health information confidential that you obtain in connection with your volunteer duties and responsibilities. This includes information about any medical condition, medical testing, medical treatment or surgery, prescription medications, dental treatment or vision treatment or any other procedure related to the health of an individual. In addition, you agree not to use or disclose this information to any person except those persons directly necessary to the performance of your duties and responsibilities. (This includes talking to another volunteer or worker about the medical information.) If you are not sure about whether or not any information is confidential, you agree to ask your supervisor or manager.
Failure to keep health information confidential may result in monetary liability, civil penalties (fines) and/or criminal penalties provided for by law.
I have read the above information and agree to keep health information confidential.
|Please Sign that you understand |
|Signature: |Print name: |
| |Date: |
|Witness Signature |
|Signature: |Print name: |
| |Date: |
If you are injured as a result of a work-related accident, your volunteer’s workers’ compensation
coverage provides medical benefits that you may be entitled to.
Medical Benefits
As soon as your carrier knows about your work-related injury, the carrier will:
• Determine the compensability of your injury
• Provide an authorized doctor
• Pay for all authorized medically necessary care and treatment related to your injury
Authorized treatment and care may include:
• Doctor’s visits • Hospitalization
• Physical therapy • Medical tests
• Prescription drugs • Prostheses
• Travel expenses to and from your authorized doctor.
Once you reach maximum medical improvement (MMI), you are required to pay a $10 co-payment per visit for medical treatment.
MMI occurs when the physician treating you determines that your injury has healed to the extent that further improvement is not likely.
Wage Replacement Benefits
Anti-Fraud Reward Program
Workers’ compensation fraud occurs when any person knowingly and with intent to injure, defraud, or deceive any employer or volunteer, insurance carrier, or self-insured program files false or misleading information. Workers’ compensation fraud is a third degree felony that can result in fines, civil liability, and jail time. Rewards of up to $25,000 may be paid to individuals who provide information that lead to the arrest and conviction of persons committing insurance fraud. To report suspected workers’ compensation fraud, call 1-800-378-0445.
• Timely provision of medical treatment
• Timely payment of medical bills
• Timely reporting of your claim information to the Division of Workers’ Compensation Department of Financial Services Division of Workers’ Compensation
Insurer Responsibilities
Employee Assistance Office
If you have any questions or concerns about your workers’ compensation benefits, first call your claims adjuster. The Division of Workers’ Compensation, Employee Assistance Office (EAO) helps prevent and resolve disputes between injured workers and employers/carriers. If the insurance carrier does not provide the benefits to which you believe you are entitled, you can call the
EAO toll-free hotline at 1-800-342-1741. EAO specialists are knowledgeable about the workers’ compensation system and may be able to address your concerns. The EAO has offices located throughout the state that you can call or visit. You can access the EAO statewide map at http: //WC/dist_offices.html. In addition, the Division of Workers’ Compensation has a website section on “Frequently Asked
RIGHTS AND RESPONSIBILITIES OF EMPLOYEES UNDER WORKERS'
COMPENSATION WITH HILLSBOROUGH COUNTY ACKNOWLEDGMENT AND RECEIPT
OF EMPLOYEE WORKERS' COMPENSATION BROCHURE
I have received a copy of the Workers' Compensation Volunteer Facts brochure from the
Florida Department of Financial Services (Revised 2003). I have carefully read and
understand its content.
Acknowledgement of Understanding of Workers’ Compensation Procedures
I understand the policies and procedures for reporting and seeking medical treatment for on-the-job injuries and accidents while volunteering for Hillsborough County Parks and Recreation. I understand that if I do not follow these procedures I may be denied certain benefits and/or may be personally liable for expenses incurred. If registering via email, your typed signature shall be substitute for and have the same legal effect as an original form signature.
|Please Sign that you understand |
|Signature: |Print name: |
ATTACHMENT 1
Background Check/Investigation Disclosure and Authorization Form
By signing the release below, I hereby authorize Hillsborough County to contact any and all corporations, former employers, educational institutions, law enforcement agencies, city, state, county, and federal courts, and military services to release information about my background including, but not limited to, information about employment, education, driving record, criminal record and general public records history to Hillsborough County.
In compliance with Section 119.071(5), Florida Statutes (Public Records Law) by this document the Hillsborough County Office discloses to you that your Social Security number is requested for the purpose of applicant and volunteer background and criminal history checks, identity verification, verification of past employment, new hire and unemployment reporting, processing employment benefits, drug screening, income reporting, Worker's Comp reporting, payroll processing and reporting will be used solely for those purposes.
I understand that my volunteer status with Hillsborough County is subject to satisfactory completion of a background check/investigation, including verification of information I supplied in my application for employment.
I release from all liability all persons, companies, and schools supplying such information. I release Hillsborough County from and indemnify Hillsborough County against any liability whatsoever in connection with such background investigation and the use of the results there from in the volunteer process. I also understand that I will be given a copy of the background check/investigation report, should any adverse action or non-selection be considered because of the results of the report.
I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release.
|Print Name: |
| |
|Alias – Other Names Used: |
| |
|Social Security Number: Driver’s License Number and State Issued: |
| | |
|Address: Date of Birth: |
| | |
|Date of Degree Received: University/School Degree From: |
| | |
|Signature of Applicant: Date: |
| | |
-----------------------
HILLSBOROUGH COUNTY PARKS & RECREATION
VOLUNTEER APPLICATION (18 YEARS & OLDER)
Please complete this application to become a registered volunteer.
Volunteer Services: 6105 E. Sligh Ave. Tampa, FL 33617
RamirezD@ (813) 744-5598 office
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- printable contact information sheet
- basic contact information sheet printable
- free printable contact information sheet
- sample contact information form
- free contact information form template
- indeed contact information 1 800
- contact information sheet word
- contact information software
- contact information for chime bank
- emergency contact information sheet template
- business contact information database
- emergency contact information form