Common Contracts
1 similar Individual Volunteer Health Care Provider Application/Protection Agreement contracts
ContractIndividual Volunteer Health Care Provider Application/Protection Agreement • January 23rd, 2014
IMPORTANT - READ PRIOR TO COMPLETING APPLICATION/ PROTECTION AGREEMENT The Individual Volunteer Health Care Provider application/protection agreement form requires two signatures upon submission. Signatures are required in "Section 5 Authorization for Release of Personal Information" and in "Section 19 Signature of Agreement ." Until this document has been signed by the DEPARTMENT, it is NOT a valid protection agreement. If approved by the DEPARTMENT, a signed copy will be returned to you. SECTION 1. GENERAL Name. Enter your first and last names. Address. Enter the mailing address for correspondence with the Volunteer Health Care Provider Program. Phone (daytime number). Enter area code and phone number. Cell Phone Number. Enter area code and phone number, if available. Email. Enter email address, if available. By providing us with your email address, you agree we may communicate with you by electronic mail. The VHCPP prefers to communicate with participants by electronic mail. License
