Name* First Last Email* Phone*Which location do you wish to shadow at?*Falls ChurchHerndonFlexible/eitherDo you want to volunteer with physical or occupational therapy?*PhysicalOccupationalDo you have a minimum and maximum amount of hours requested?*NoYesMinimumMaximumWhat is your availability?*What year are you anticipating to matriculate to a graduate program?*Choose Year20202021202220232024202520262027Please attach a resume to the request* Drop files here or Accepted file types: jpg, pdf, doc, docx. jpg, pdf, doc, docx file types acceptedConsent*I understand that Good Beginnings makes every effort to maintain a safe and risk-free work environment. However, I understand I will be working with children and there are inherent risks associated with this work. I hereby release and forever hold harmless Good Beginnings and its respective officers, employees and agents from and against all claims, actions, costs, damages and expenses with respect to damage and/or bodily injury to me as a result of my volunteer activities with Good Beginnings. Good Beginnings Staff HIPAA Policy Acknowledgement All staff members are required to follow Good Beginnings’ guidelines regarding compliance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA). The main goal of HIPAA is to ensure that client information, which is confidential, is kept confidential. Good Beginnings’ guidelines are outlined below. · Electronic medical records are confidential and must be kept secure at all times. · Only parents and others specified on our Authorization for Release of Information form are allowed to receive information on our clients. Parents fill out and sign this form at/prior to their child’s first appointment and the original, signed form is scanned to the patient's electronic medical record. Please review the completed form to determine with whom you are authorized to speak (ex., nanny, grandparent, other relatives, etc.). · Client information may not be discussed in any area of the clinic where non-staff members are present. However, a parent may agree to speak with a therapist about his/her child in the waiting room and will have indicated this on the Authorization for Release of Information form. The therapist must review this form prior to speaking with a client’s parent or designee in the waiting room. · If a parent does not want to speak about his/her child in the waiting room, the therapist may use another empty room (if available) for the discussion or offer to call the parent at another time. · Good Beginnings’ clients (and, therefore, parents) have the right to inspect, copy, and amend their files. Clients and parents also have the right to know who has asked for information from their electronic medical records. Therapists are required to document all information requests in the contact log (date and with whom you spoke, emailed, etc.). · Therapists should address any questions or concerns regarding client information and/or confidentiality with a Good Beginnings’ Director or the Practice Manager. I have read the above guidelines, acknowledge that I understand them and will abide by them.*Date* Date Format: MM slash DD slash YYYY Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.