Rainbow Kidz Volunteer Application

Thank you for your interest in volunteering with Rainbow Kidz! There are currently two ways to volunteer within our program:

Direct Volunteer: Interact with children by providing emotional support and companionship in a therapeutic group setting. The first opportunity to work directly with children will be at Camp Rainbow during the summer and requires attending our 6-hour mandatory training in the spring.

Indirect Volunteer: Provide support with tasks not directly involving children. This could include office administrative tasks, fundraising events and other year-round opportunities.

If you have any questions please call Leigh Ann Darty, Director of Rainbow Kidz, at (704) 924-4313 or email at leighannd@hoic.org.

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Work Experience

Briefly describe previous work experience(s). You may choose to list work that is relevant to children's grief counseling or other areas of work.

Volunteer History

Examples: church, community, school, non-profits, etc.

What brings you to Rainbow Kidz?

Tell us why you are interested in volunteering with the Rainbow Kidz program.

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In what capacity do you know this person?

Statement of Confidentiality

I understand I am to protect and safeguard all Hospice & Palliative Care of Iredell County information, systems and materials and keep them in strict confidence. I will keep all information and records of any patient and/or caregiver, vendor or contractor of Hospice & Palliative Care of Iredell County in strict confidence and will not disclose any such information to any third party. I understand I am expected to comply with applicable law and to keep strictly confidential all information concerning a patient’s condition, treatment, personal affairs and records.

In addition, I am expected to comply with Hospice & Palliative Care of Iredell County’s policies regarding records and release of information. I hereby recognize this statement of confidentiality acknowledging receipt and understanding of policies regarding confidentiality. I understand improper disclosure of confidential information could lead to my immediate termination.

By typing my name I have read the above Statement of Confidentiality and agree to its terms.

Use of Image/Voice/Written Testimonials Terms

Type of information to be released: Video images, photographic images, conversations, sounds, and audiotapes of individuals or groups as they participate in HPCIC sponsored events. This consent will also include verbal and/or written testimonials and statements, including biographical information and protected health information of the individual identified below.

Purpose of request: To videotape, photograph and record audio of patients or participants in programs offered or coordinated by HPCIC. These videotapes, photographs and audio recordings may be used for marketing purposes, including but not limited to production of recordings, brochures, advertisements, internet stories, social media, videos and similar image and sound capture for purposes of publication and/or distribution via all types of media.

Persons authorized to receive information: I agree that the publication and distribution of the personal or protected health information described herein may and likely will include distribution of such information to the general public via various methods, including all types of media outlets (e.g., TV, radio, newspaper, internet) for HPCIC’s marketing purposes. I also understand HPCIC may hire third parties to capture the image and/or voice recording of the individual identified below and that any information will be used and disclosed by these third parties as instructed by the organization.

Expiration and right to revoke Authorization: Except to the extent that action has already been taken in reliance on this Authorization, at any time I can revoke by submitting a notice in writing to the HPCIC’s Compliance Officer at 2347 Simonton Road, Statesville, NC, 28625.

Re-disclosure: I understand that the information disclosed by this Authorization may be subject to re-disclosure by anyone receiving it and the information disclosed will no longer be protected by the Health Information Portability and Accountability Act of 1996 (HIPAA). HPCIC’s employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

By typing my name I agree I have read the Authorization for Use and Disclosure of Image, Voice and/or Written Testimonials and the Authorization for Use and Disclosure of Personal or Protected Health Information.

Use of Image/Voice/Written Testimonials Agreement

I grant permission for HPCIC to photograph / video / interview myself for educational purposes or to promote the Rainbow Kidz Program of Hospice & Palliative Care of Iredell County. I signify that I have read The Authorization for use and Disclosure of Image, Voice and/or written testimonials and agree to terms and conditions listed therein.

By typing my name I agree to the terms of Use of Image/Voice/ Written Testimonials.

If you do not grant HPCIC permission for photographs/videos/interviews, please type "No".

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