DOWNTOWN EMERGENCY SERVICE CENTER
GROUP PARTICIPANT/SPECIAL PROJECT
VOLUNTEER APPLICATION

Please fill out this application in its entirety. It is a required form for anyone participating in a group activity or special project at DESC.

Thank you for your interest in volunteering at DESC!

PERSONAL INFORMATION
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Communications Release - I hereby give the Downtown Emergency Service Center my free and unlimited consent and permission, waiving all claims for any compensation by reason thereof or for damages by reason thereof, to use, publish, republish, or exhibit in the furtherance of its work, with or without identification of me by name, the photographs, videos or statements taken on this day of volunteering, and to disseminate statements referring to me in conjunction therewith if the Downtown Emergency Service Center so desires and to authorize any newspaper, company or other organization to use, publish, republish or exhibit said photograph with or without identification of me by name and to publish or disseminate statements referring to me in conjunction therewith in the promotion of the Downtown Emergency Service Center and any of its fund campaigns or any of its activities.
** Please enter your name in the field below to confirm that you have read, understand and agree to the liability and communications release statements above.
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I (above named individual) agree not to divulge, publish or otherwise make known to unauthorized persons, any information regarding clients, former clients or persons applying to become clients, obtained through DESC or other public and private agencies. I understand that DESC shares client information with other individuals and agencies only on a clear need-to-know basis. I agree to protect the privacy of DESC clients and that personal information gained about and/or observations of clients will be handled in accordance with agency policy, contract requirement, state law (Revised Code of Washington 70.96A, 71.05, 71.24, 7.34 and Washington Administrative Code 388-877), federal regulations (42 Code of Federal Regulations), with HIPAA (Health Insurance Portability & Accountability Act of 1996), and with all other applicable laws and regulations. I further agree to comply with the Washington State client rights protections in Washington Administrative Code 388-877, 388-877A, and 388-877B. If I have doubt about releasing information about a client, I will consult my supervisor and/or program manager. I understand that my obligations to protect client confidentiality continue despite any termination of employment/internship/volunteer or change in job responsibilities. I recognize that unauthorized disclosure of confidential information may subject me to DESC disciplinary action up to and including termination of my employment, and may subject me to civil liability under the provisions of Washington state law (Revised Code of Washington 70.02.170 and 71.05.440) and/or to federal criminal proceedings (42 Code of Federal Regulations), and/or additional liability under other applicable laws and regulations.
I agree to protect the privacy of DESC clients and that personal information gained about and/or observations of clients will be handled in accordance with agency policy, contract requirement, state law (Revised Code of Washington 70.96A, 71.05, 71.24, 7.34 and Washington Administrative Code 388-865 & 388-805), federal regulations ((42 Code of Federal Regulations), with HIPAA (Health Insurance Portability & Accountability Act of 1996), and with all other applicable laws and regulations.
I further agree to comply with the Washington State client rights protections in Washington Administrative Code 388-865-0410. If I have doubt about releasing information about a client, I will consult my supervisor and/or program manager.
I understand that my obligations to protect client confidentiality continue despite any termination of employment/internship/volunteer or change in job responsibilities.
I recognize that unauthorized disclosure of confidential information may subject me to DESC disciplinary action up to and including termination of my employment, and may subject me to civil liability under the provisions of Washington state law (Revised Code of Washington 70.02.170 and 71.05.440) and/or to federal criminal proceedings (42 Code of Federal Regulations), and/or additional liability under other applicable laws and regulations.
** Please enter your name in the field below to confirm that you have read, understand and agree to the confidentiality agreement statements above.
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