Volunteer Application

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Volunteer Application and Waiver

1500 SE 19th Street, Suite 530, Grimes, IA 50111
Phone: 1-866-282-5817
Fax: (515) 327-5422
www.safenetrx.org

Join our team today!
Personal Information
Name:
Street Address:
Phone Number:
Email:
How did you hear about this volunteer opportunity?:
If Other, please specify:
Emergency Contact
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone Number:
Education
Highest Level of Education Completed:
Name of Institution:
Degree (if applicable):
Availability
We are very flexible with volunteer time - Morning shifts are typically 8:30AM - 12:30PM and afternoon shifts are from 12:30PM - 4:30PM. Once this application is completed, you will have the opportunity to sign up for volunteer shifts.
Describe availability (please note if you are attending a one-time volunteer event):
I am flexible and would like to be contacted if a need arises at SafeNetRx:
Volunteer Opportunities
I am interested in:
Disclosure
Have you ever been convicted of any felony?:
If yes, please describe:
Hazardous Drug Volunteer Risk Acknowledgement
I understand SafeNetRx, receives drugs determined hazardous by the NIOSH List and USP<800>. I understand that working with, or near, hazardous drugs in this setting may cause cancers, birth defects, miscarriage, infertility, and skin irritations. Best practices recommend wearing gloves while handling hazardous drugs and SafeNetRx is responsible for providing that protection to me. I understand failure to follow best practice methodologies may put me at greater risk of exposure to hazardous drugs, and may lead to adverse effects such as cancers, birth defects, miscarriage, infertility, and skin irritations.
I have read and understand to the Hazardous Drug Risk Acknowledgement:
Image Release
I hereby grant SafeNetRx the rights to use my image, voice, and other reproductions of my physical likeness in perpetuity in connection with any form of advertising or marketing SafeNetRx produces or prepares for displays, publicity, educational programs, and/or public relations.
I have read and agree to the Image Release:
Release and Waiver
I understand that as a volunteer I may be required to lift items up to 30 lbs. or be required to sit or walk for extended periods of time. By submitting this application to become a SafeNetRx volunteer, I state that I am capable of performing these tasks and waive and release any and all claims I may have against SafeNetRx in the course of volunteering. I understand that I am not entitled to any employee benefits such as worker's compensation, salary, or any other benefits compensation.
I have read and agree to the Release and Waiver:
HIPAA Training
All volunteers are members of the SafeNetRx Workforce and are required to comply with HIPAA laws. I understand that I will see confidential protected health information and that I am required to follow all HIPAA requirements. All volunteers will receive orientation regarding HIPAA before being allowed to volunteer.
I certify that I have completed HIPAA training through::
Name of Institution (if applicable):
I have read and agree to the Confidentiality Agreement linked at the bottom of this application:
Acknowledgement
By signing my name below, I represent that the information provided is true and correct.
Are you a parent or guardian signing on behalf of a minor?:
Electronic Signature:
Date:

Attached Documents

HIPAA Training Course

Volunteer/Rotation Student Confidentiality Agreement

SafeNetRx is a 501(c)3 non-profit organization with a mission to serve vulnerable populations through responsible collection and distribution of donated medicines.

SafeNetRx

1500 SE 19th St, Ste 530, Grimes, IA 50111

Phone: 1-866-282-5817
Fax: 515-327-5422
Email: repository@safenetrx.org

About Us

Our Team

Drug Donation Repository

Charitable Pharmacy