Wufoo

Informed Consent for WVU Medicine Volunteer Services Program Participants

I agree to take part in the Volunteer Services Program at WVU Medicine. I understand that volunteers are not permitted to provide or assist with direct patient care. Some
examples of direct patient care include, but are not limited to, giving medication, bandaging, injections, suturing, and bathing.

If I am unsure of what to do in a given circumstance, I will seek advice from my immediate supervisor. If I feel that my supervisor has not provided me with sound ethical advice, then I will refer to the hospital’s compliance plan and I will call the compliance hotline that is included in my orientation packet. *
I agree.
Behavioral Standards *
I agree.
Dress Code *
I agree.
HIPAA *
I agree.
Patient Right & Responsibilities *
I agree.
Name * First Last
By checking this box you have created an electronic signature as legally binding as your hand-written signature: *
I agree.
Date * MM / DD / YYYY
If your are under the age of 18, your parents must fill out the following items:
Parent name First Last
By checking this box you have created an electronic signature as legally binding as your hand-written signature:
I agree.
Date MM / DD / YYYY
Do Not Fill This Out

This site is protected by reCAPTCHA Enterprise and the Google Privacy Policy and Terms of Service apply.