Volunteer | Arts for Smiles

Arts for Smiles Inc.

Volunteer Application

Date

First name

Last name

Phone

Email

Birthday

Month

Day

Year

Languages spoken in addition to English?

Current Employer or School?

Previous Volunteer Experience?

How would you like to assist Arts for Smiles? (List any that apply. Please note that working directly with the children might require a background check.)

Do you agree to comply with the privacy/confidentiality safeguards as applied under HIPAA?

Yes

No

Unsure

Do you agree to refrain from posting any photos or videos on social media or sharing private information with others regarding the children and families?

Yes

No

Do you consent to a photograph release for any events and/or activities you take part in with Arts for Smiles Inc. and consent to said photos being posted on social media or other Arts for Smiles Inc. materials?

Yes

No

How did you hear about Arts For Smiles?

Do you have any allergies or medical concerns? Please list them here.

Printed Name:

Applicant's Signature:

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MINOR APPLICANTS - PARENTAL CONSENT REQUIRED:

I give consent for my minor child to serve as a volunteer with Arts for Smiles Inc. I also attest that said minor understands the HIPAA/Confidentiality laws and will follow appropriate safeguards to protect the privacy of the children and the families we help. These safeguards include, but are not limited to, the posting of photos or videos on social media. (Exceptions will strictly be limited to providing any images/videos to our Arts for Smiles Inc staff, and they may post.) In addition, I give my consent for my minor child to be part of Arts for Smiles Inc. social media posts and consent to a photo release on behalf of my minor child.

Child's Name

Parent's Name

Parent/Guardian’s Signature

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