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For more information contact:

Rachelle Hadley, Director of Volunteers
402-499-6470 (phone)
888-317-8608 (fax)

Current license type?
Emergency Contact
Select local hospitals where you are credentialed
Do you have professional liability insurance (check all that apply)?
If you are a Physician Assistant, do you have a supervising physician who will cover you while you volunteer at Clinic with a Heart?
What languages do you speak (check all that apply)?
Are you affiliated with any of our mission teams (each has a night of service each month)?
Have you ever been convicted of a felony?
Have you ever been convicted of a misdemeanor?
VOLUNTEER STATEMENT: I wish to donate my services to Clinic with a Heart as a Medical Provider through the Volunteer Services Program. I understand that there is no payment or billing for services rendered under the Volunteer Program of Clinic with a Heart. I also understand that photographs may be taken from time to time for publication or other uses. I agree to abide by the rules, policies, and procedures of Clinic with a Heart. I agree to inform Clinic with a Heart Administration of any pending disciplinary action, pending legal action or instituted legal action, investigation regarding privilege/credentialing status or licensure, and/or any change of status with any of the information provided on this application. I understand that a current Nebraska license is required (license type specified above).
My signature on this application provides my authorization for Clinic with a Heart to contact and receive information from local hospitals pertaining to my appointment and credentialing status. I hereby waive any and all claims that I may have against all persons giving, receiving, or acting upon said information concerning me to the fullest extent permitted by law. This Authorization continues unless otherwise revoked by me in writing.
I understand Clinic with a Heart’s Professional Liability Insurance does not include coverage for licensed physicians and dentists while practicing at Clinic with a Heart. I further understand that physicians, dentists, and chiropractors will be required to have in effect current individual Professional Liability Insurance that covers their practice at Clinic with a Heart. Additionally, I understand that physician assistants, APRNs, pharmacists, mental health providers, and physical therapists with active licenses are covered by Clinic with a Heart’s Professional Liability Insurance when practicing at Clinic with a Heart.

VOLUNTEER STATEMENT: I am at least 19 years of age and I wish to donate my services to Clinic with a Heart. I understand there is no payment for services rendered. I understand I may be asked to participate in photos of CWAH activities without expectation of any type of remuneration. I understand I may be subject to corrective action or dismissal from the CWAH volunteer program for failure to abide by the policies and procedures of CWAH. To the best of my knowledge I am in good health and able to perform assigned duties.


In consideration of the participation of the undersigned (the “Team Member”), an individual who is at least 19 years of age, in or with Clinic with a Heart, Inc., a Nebraska nonprofit corporation (the "Clinic”), the receipt and sufficiency of which is expressly acknowledged, Team Member understands, warrants and agrees as follows (the “Agreement”):

1. Release of Liability.

Team Member acknowledges and agrees that:

  • Healthcare, in any form and especially involving donated services in free clinic settings can be an inherently dangerous activity, carrying the significant risk of serious personal injury or death;
  • The conditions and risks are frequently beyond the control of the Clinic and the Clinic is not able to completely mitigate such risks to the Team Member; and
  • Team Member shall, at all times be responsible for, and shall be required to exercise all reasonable care for his/her own safety.

Except to the extent covered by the Clinic’s Blanket Accident Insurance policy, Team Member, for him/her self, spouse, successor, and heirs, does hereby release, waive, absolve, discharge and agree to hold harmless the Clinic, including other Team Members and the Clinic’s representatives, officers, directors, employees, agents, affiliates, insurers and attorneys (collectively, the "Released Parties"), from and against any and all rights, claims, demands, causes of action, obligations, suits, liens, damages or liabilities of any kind and character whatsoever, whether known or unknown, suspected or claimed, which Team Member shall or may have in the future against the Released Parties arising out of, based on, related to or connected with Team Member's participation in any Clinic related activities.

2. Personal Responsibility.

Team Member agrees that upon becoming a volunteer with the Clinic, he/she WILL:

  • Adhere to the Policy and Procedures of Clinic with a Heart. Stay informed about Clinic operations, events, and changes by accepting and reading the monthly electronic newsletter and communication memos from the Clinic;
  • Participate in relevant educational offerings;
  • Record volunteer work time in and out and position worked;
  • Know his/her team/discipline assignment and his/her team/discipline leader and how to contact him/her;
  • Utilize his/her team/discipline sign up scheduling system in advance of the clinic/meeting, and if unable to fill a work commitment, notify the team/discipline leader in advance;
  • Learn and perform the duties of his/her position and seek assistance if needed;
  • Treat patients, guests, and other volunteers with dignity and respect;
  • Share concerns or ideas for improvement with a team leader or Clinic staff;
  • Participate in the welcoming and orientation of new Clinic volunteers. 

3. Additional Terms.

Team Member acknowledges that the Agreement is executed in exchange for the opportunity to participate in the Clinic and the Clinic related activities. This Agreement shall remain in force until written revocation thereof is delivered to the Clinic, however, Team Member recognizes that such revocation will result in Team Member being prohibited from further participation in the Clinic and the Clinic related activities. The Clinic reserves the right to terminate Team Member’s participation in the Clinic and Clinic related activities at any time in its sole discretion with or without notice.

Team Member has read the Agreement in its entirety, understands it, voluntarily agrees to it, and further understands that Team Member has given up substantial rights by signing it. The person(s) signing this document has full authority and capacity to do so. If any portion of this Agreement is found to be invalid, the remainder shall continue in full force and effect. This Agreement shall be binding upon the Team Member and his/her respective heirs, personal and legal representatives, and successors.