Our Volunteer Team

The following requirements must be completed prior to attending a volunteer orientation:

• Submission of completed and signed volunteer application and reference form.
• Documentation of a negative TB skin test (PPD) or negative TB chest x-ray within the last 6 months. The clinic will administer your TB skin test, if you have not had one done prior, at your orientation.
• Documentation of annual vaccination against influenza between October 1st and April 30th. This is required in order to volunteer during the influenza season listed above.
• If you are volunteering in a clinical capacity, documentation of current active or volunteer status professional licensure/certification.
• Completion of PA DHS Act 153 Background Clearances for Volunteers packet:
  • PA State Police Criminal Record Check – go to epatch.pa.gov/home and fill out the “New Volunteer Record Check”.
  • PA Child Abuse History Clearance – go to compass.state.pa.us/CWIS. Create a new account and follow the directions carefully.
  • FBI Fingerprint Clearance – go to identogo.com/locations/pennsylvania or uenroll.identogo.com. *If you have lived in Pennsylvania for 10 straight years, you may forego the FBI check and obtain a notarized affidavit instead. This can be completed at orientation.

My signature on this form is evidence that I have decided for my own personal reasons to volunteer my services to the Ann Silverman Community Health Clinic (ASCHC) and that I understand, acknowledge, and agree to the following:

1. To abide by all volunteer and clinic and hospital policies and procedures.
2. I affirm that all information provided during the application process is true and correct.
3. The services that I perform in connection with the ASCHC are freely donated by me and I do not expect to receive any compensation for these services.
4. I will not volunteer during my regular working hours or scheduled overtime hours for Penn Medicine Doylestown Hospital if I am currently employed by Penn Medicine Doylestown Hospital.
5. I give permission to ASCHC to investigate any and all information concerning my application in order to determine my qualifications. This includes, but is not limited to, medical clearance, criminal background checks, employment, and personal reference checks. Falsification of information provided in this application will result in non-admission or dismissal from ASCHC’s volunteer program.
6. I understand my obligation to maintain the complete confidentiality of any and all information in order to protect applicants and patients of the ASCHC and their families, as well as all members of the ASCHC and Penn Medicine Doylestown Hospital family from improper disclosure of information given in confidence.
7. If a person is injured while volunteering for the ASCHC, the incident must be immediately reported to the Executive Director of the ASCHC. All bills are first submitted to the injured person’s primary insurance carrier. In appreciation of the volunteer’s service, the ASCHC will pay any uncovered costs. I understand that I am not covered under Workman’s Compensation Insurance during my volunteer work with the ASCHC.
8. I agree to return my ID badge to the ASCHC upon my resignation or termination from ASCHC.
9. My signature below indicates that I have read, understood and consented to the statements above. This authorization or a photocopy shall serve as consent for ASCHC to request information concerning my application.

Please provide a person of your choice (not family) who can give a reference in support of your application. The clinic will send this person the Volunteer Applicant Reference Form. Responses can also be mailed directly to the clinic at 595 West State Street, Doylestown, PA 18901, Attn: Volunteer Coordinator.