This is a new registration system as of September 2019, so if you made a volunteer RAM/Health Wagon account prior to September 2019 your information is not in this new system. We are sorry for any inconvenience that this may cause.

We are so thankful for your interest in volunteering with The Health Wagon at our Move Mountains Medical Mission M7 (Formally Wise RAM event) on July 10, 11 and 12, 2020. After twenty years of collaborating with Remote Area Medical (RAM), The Health Wagon will now be overseeing this event as we have grown and now RAM can turn their efforts to other underserved areas. We are excited to continue this tradition in 2020 under a new event name "Move Mountains Medical Missions" M7 for short. We have seven core programs which include Dental, Vision, Medical, Behavioral & Mental Health, Advanced Diagnostics, Veterinary and Spiritual. We have expanded the vision to incorporate the whole picture of our patient's health. We are excited to meet you and have you become a part of our mission to serve our underserved community. We hope to be adding more events in the future and hope for your continued support for years to come.

Your information WILL NOT BE SAVED until you hit the submit button at the end of the registration.

If your plans change or you are unable to attend the event please cancel your volunteer registration as soon as possible so we can ensure we have enough volunteers to maintain the Move Mountains Medical Mission (M7). To do so please use the RECALL MY INFORMATION button to pull up your assignments cancel yourself or change your dates of attendance.

 
      If you previously registered on this webpage, we will recall your information.
Do not RECALL your information and type over it for another family member. That overlays the existing record.
 
 
Abbreviated Title   Example: Mr., Ms., Dr., Hon.
 
     
Professional Abbreviations       Example: DDS, MD, PhD
Name on Badge       List the information you want to appear on your badge.
Example: Dr. Jeff, Ms.King, Sam
 
 
  If possible, we would like to text you with occasional reminders and pertinent updates.
Mailing Address Line 1   Include apartment, suite or box number, if applicable.
Mailing Address Line 2  
 
 
 
  We recommend an email address unique to the registered volunteer instead of a shared office address or the personal address of a group leader for all group members. We will send personalized scheduling correspondence to this address.
 
        
  Establish your unique User Name. You may use your email address as your User Name unless another registered volunteer will be receiving correspondence at that same address. 
        
  Used to recall your information when you visit this site again so you can make changes and/or select additional volunteer opportunities.  Your password must be at least 6 characters.
 
       
Required Age
  I will be at least 14 years of age when I volunteer. Volunteers under 18 must email volunteers@thehealthwagon.org for the Minor Release Form.
  For legal reasons these are the age restrictions for volunteering.
 
T-Shirt Size   T-Shirt style is adult unisex.
Language Fluency (other than English)
Select all that apply
  Hold down the control key to select more than one language.
Hold down the control key and click on a selected language to de-select it.
         
Other Information
    Blood Borne Pathogen Training     Have you taken an infection control/ blood-borne pathogen certification training?
    Vaccinated for Hepatitis B    
          
Company / Organization   Optional, but helpful to know especially if you're coming with an office or team.
Matching
My company has a matching program
  Please indicate if your employer matches your donated time with a financial donation to the non-profit where you volunteer.
Description   Describe the program requirements and let us know how we can help - provide information for anyone we must contact and/or list any documentation you might need etc.
 
First and Last Name  
Relationship    
Phone    
   
Event Area
  Select the area appropriate to your profession / classification.
Profession / Classification
General Notes
(if needed)
 
License Number   Enter "none" if a license is optional for your profession and you do not have a license. Set the Expiration Date in the future.
Expiration Date    
Prof. Liability Insurance Carrier   Professional malpractice insurance is your responsibility. Write "NONE" if you do not have any and reach out to The Health Wagon to learn more about being added to our insurance plan.
State of Licensure   Out-of-state providers MUST follow the procedures for out of state volunteers.

Only U.S. licensed professionals are able to volunteer as healthcare providers.

License Comment   List additional information we should know. Examples: You selected Other Professional - indicate field/specialty. Your license will renew before the clinic. You are licensed in a second field - provide license details.
     
Residency Location  
Residency Supervisor  
     

We welcome student participation at our clinics! We have three main types of student participation:

  1. Pre-Health: If you are in a pre-healthcare track (pre-med, pre-nursing, pre-dentistry, etc.), please select "General Support" as your assignment. Since you are not a licensed medical professional, we could use your help as a General Support volunteer where your tasks may range from helping in patient registration to dental sterilization, depending on your interests and our needs at the clinic. We are excited for your to get some volunteer experience with us!
  2. In Professional School - No Supervisor Present: If you are in medical, nursing, dental, etc. school yet you do not have a licensed faculty supervisor accompanying you to the clinic, you will not be able to practice patient care at The Health Wagon clinic. This means you will not be able to provide any medical services or treatments to our patients. You are welcome to sign up for your respective field's "Support" category. (i.e. Dental Support, Vision Support, Medical Support). This will allow you to assist the professionals in that clinic area by helping with patient flow, serving as a scribe to the licensed professional, etc. This is a great opportunity for your to gain shadowing experience or talk to professionals in the field you are studying while also helping The Health Wagon clinic to run smoothly. Please fill out your school's information below.
  3. In Professional School - Supervisor Present: If you are in medical, nursing, dental, etc. school and you do have a licensed faculty supervisor that will accompany you to the clinic and if you are at least over halfway finished with your program and well into clinical rotations, then you will be able to practice patient care under your faculty's supervision. However, that supervisor must contact us at: volunteers@thehealthwagon.org This is how our Volunteer Coordinators will provide the correct information, discuss the requirements, and approve your school for a specific clinic. Once you have been approved, you will be able to select a student assignment that will show up as your student type and your university ("Nursing Student - University of Tennessee"). Please fill out your school's information below.
School    
Field of Study / Degree Program    
Year of Study    
Onsite Faculty Supervisor    
       
 
Event
  Signing up for more than one clinic?

Great! Finish your registration and pick your assignments for your first clinic, then click

SAVE AND SUBMIT at the bottom.

THEN, click the RECALL button at the top to pull up your record, scroll down, and pick your assignments for the second event (and repeat).

 
Event Location
---
  More detailed directions will be available prior to your arrival.
Event Email
---
  Please add this information to your safe senders/callers list.
Event Phone
---
 
Event Information
 
 
Please select an assignment for each day you plan to attend.

- Waiting Lists: if your preferred assignment is full, a waiting list option may be shown. If you choose to be on the waiting list for your preferred assignment, you will also be given the option to select an alternate assignment. If an opening becomes available in your preferred assignment, you will receive an email notice (and, if selected, a text message) automatically moving you to your preferred assignment. This will automatically cancel you from the alternate assignment.

    
Admin Code
For administrative or instructed use only.
Day Type Assignment
   
     
   
Select your profile picture   Please upload a photo if you have one available so we can get to know you better. We also will be doing volunteer highlights in social media when confirmed.
Your current picture
   
Please upload a copy of your medical license, certifications etc...
Document 1 Name      
Document 2 Name      
Document 3 Name      

No files have been uploaded

   
All volunteers must agree to The Health Wagon's Terms and Conditions. Please contact us for more information.

Please read all provisions of this Release and Waiver of Liability and Participation Agreement (the “Agreement”) carefully before signing.

1. Acknowledgment and Acceptance of Risk/Informed Consent.

In arranging various outreach programs for volunteers, THE HEALTH WAGON (M7), makes every effort to protect the welfare and safety of its volunteers and participants. Recognizing, however, that participation in these events are voluntary and that there are certain inherent risks that volunteers and participants voluntarily assume, I understand and agree that neither THE HEALTH WAGON’S (M7), or its officers, directors, employees, agents, representatives, nor any cooperating institution, assumes any responsibility for damages to or loss of my property, personal illness or injury, or death to me while I participate in the event. By voluntarily participating in this outreach volunteer event, I freely assume any risk associated with or arising out of traveling, conducting research and engaging in community service. I further acknowledge that it is my responsibility to review U.S. State Department travel advisories, warnings, or other information available through the U.S. Department of State and freely assume any and all risks which may arise, concern, or relate to the conditions contained in any advisory statements, warnings or other information. I also acknowledge that I am free to seek out any additional information I may desire before I choose to travel and volunteer. I agree that, as a conditions of participating in any event, my decision to travel and volunteer is solely my choice and that I voluntarily assume any and all related risks concerning such activities, including the risk of needing additional information upon which to make an informed choice about whether to participate in such activities.

2. Donations.

THE HEALTH WAGON’S (M7) encourages volunteers to help with donations and to get other individuals to make donations to its medical and dental supply funds. Community outreach helps ensure this event continues to function year after year. All donations will be used to purchase necessary medications, medical and dental supplies to be used during our events. Any donations made by or on behalf of a volunteer or an individual to any medical supply fund or dental supply fund are non-refundable donations. Donations made to THE HEALTH WAGON’s (M7) are tax deductible. Please contact The Health Wagon directly for more information.

3. Insurance; Travel Documents.

I agree that it is my responsibility, and a condition of participation in THE HEALTH WAGON’S (M7) event, to ascertain whether I have adequate health and accident coverage and to procure adequate health and accident coverage, and any other insurance coverage as I may deem necessary. Furthermore, I understand that it is my sole responsibility to review such coverage and obtain any additional coverage that I deem appropriate. I understand that I am responsible for any costs associated with travel expenses, airport taxes, obtaining the proper travel documents, and changes to flight itineraries.

4. Program Changes and Cancellations.

I understand and agree that, although THE HEALTH WAGON’S (M7) will attempt to maintain the event as described in its publications and brochures, it reserves the right to change the event, including the itinerary, travel arrangements, or accommodations, at any time and for any reason, with or without notice, and that neither THE HEALTH WAGON’S (M7), nor its officers, directors, employees, agents, or representatives shall be responsible or liable for any expenses or losses that I may sustain because of these changes.

Further, THE HEALTH WAGON’S (M7) reserves the right to cancel any event if there are insufficient registrants or if THE HEALTH WAGON’S (M7) determines it is in the best interest of the volunteer’s safety and quality of programming to cancel the event. THE HEALTH WAGON’S (M7) is not responsible for other costs incurred by applicants preparing for the trip to the event.

5. Removal from Program.

I understand and agree that THE HEALTH WAGON’S (M7) reserves the right to decline to retain me in the event at any time if my actions or general behavior, in the sole discretion of THE HEALTH WAGON’S (M7), or its officers, directors, employees, or agents, is determined to impede or to obstruct the progress of the program in any way or if I fail to follow THE HEALTH WAGON’S (M7)’s policies.

6. Waiver, Release, and Hold Harmless.

I understand and agree that, although THE HEALTH WAGON’S (M7) has made every reasonable effort to assure my safety while participating in the program, there are unavoidable risks in travel. I do hereby forever and absolutely waive and release any and all claims against THE HEALTH WAGON’S (M7), its officers, directors, employees, agents, representatives, and any event organizer or operator employed by THE HEALTH WAGON’S (M7) (collectively, the “Releases”), arising out of or relating to my participation in the event, including but not limited to, claims for any injury, loss, damage or accident, delay or expense resulting from the use of any vehicle, any strikes, war, acts of terrorism, weather, sickness, quarantine, government restrictions or regulations or arising from any act of omission of any steamship, airline, railroad, bus company, taxi service, hotel, restaurant, school, university, or other firm, agency, company or individual or any other related matter. I also release the Releasees and agree to indemnify and hold them harmless, with regard to any financial obligations or liabilities that I may personally incur or any damage or injury to the person or property of others that I may cause, while participating in the named event. I further agree that the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts.

7. Local Laws and Prohibition of Illegal Drugs.

I understand and agree that breaches of the local law of the host community or country will be referred to and handled by the appropriate law enforcement authorities. I further agree that the use of illegal drugs in any form, as governed by the laws of the United States of America, will not be tolerated and will be grounds for immediate removal from the event.

8. Health and Safety.

(a) I represent and warrant I have consulted with a medical doctor or will consult with a medical doctor with regard to my personal medical needs prior to participation in THE HEALTH WAGON’S (M7)’s event. I represent and warrant that there are no physical or mental health-related reasons, problems or special dietary requirements or restrictions which would preclude or restrict me from safely participating in THE HEALTH WAGON’S (M7)’s event.

(b) In the event I suffer any injury or illness while participating in THE HEALTH WAGON’S (M7)’s event, I hereby authorize the representative of THE HEALTH WAGON’S (M7), at my expense, to secure necessary treatment, including, but not limited to, the administration of an anesthetic and surgery, and such medication as may be prescribed. I further assume any and all risks associated with or arising from any such medical treatment and agree to waive any and all claims which I might assert against THE HEALTH WAGON’S (M7), or its officers, directors, employees, agents, or representatives for such medical treatment. Notwithstanding the foregoing, this consent to medical treatment does not constitute an obligation on the part of THE HEALTH WAGON’S (M7) to secure any such treatment on my behalf.

9. Veterinary Volunteer Waiver.

I represent and warrant that in addition to the representations, acknowledgements and releases I have made herein, if I am a veterinary volunteer, I understand that I will be in contact with both domestic and/or wild animals. I acknowledge the nature of the activities to be performed by me and recognize that in handling both domestic and/or wild animals, a risk of harm, injury, illness, death, or disease exists, including physical harm, illness, death, or disease caused by animals. I acknowledge and agree that all veterinary volunteer activities are to be performed by me at my own risk and I assume full responsibility, therefore.

In consideration for permitting me to provide volunteer services to THE HEALTH WAGON’S (M7), on behalf of myself, my heirs, personal representatives, and executors, and any others who claim through me, I agree not to hold or attempt to hold the Releasees liable for any death, injury, illness, disease, or damage sustained or incurred by me arising out of, or in any way, connected with my veterinary volunteer activities for THE HEALTH WAGON’S (M7) event and I do hereby forever and absolutely waive and release any and all claims against the Releasees, for any such injury, damage, accident, disease, quarantine, illness or any other related matter incurred or suffered by me as a veterinary volunteer. I also release the Releasees and agree to indemnify and hold them harmless, with regard to any financial obligations or liabilities that I may personally incur or any damage or injury to the person or property of others that I may cause, while participating in the named event as a veterinary volunteer.

10. Image Release Form.

I hereby grant THE HEALTH WAGON’S (M7), its successors, assigns, and legal representatives (“THE HEALTH WAGON’S (M7)”) the irrevocable right to use my name, photograph, image, audio recording, video recording, and/or likeness (the “image”) in all forms and manner, including, but not limited to, photographs, videos, or other digital media in any and all of its publications, including Internet web-based publications, websites, promotional material, or for any other similar purpose, without payment or other consideration to me.

I understand and agree that all images will become the property of THE HEALTH WAGON’S (M7) and will not be returned. I hereby irrevocably authorize THE HEALTH WAGON’S (M7) to edit, alter, copy, exhibit, publish, or distribute these images for any lawful purpose. I waive any right to inspect or approve the finished product wherein the image appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the image.

I hereby hold harmless, release, and forever discharge THE HEALTH WAGON’S (M7), and its owners, officers, directors, successors, assigns, and legal representatives from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have arising out of or in connection with this authorization. This Image Release shall be governed by the laws of the state of Virginia.

11. Covenant Not To Sue.

I promise and agree that I will not sue THE HEALTH WAGON’S (M7), or any of its operators, or parent, subsidiary and related entities, or its or their respective officers, directors, employees, agents, and insurers for any damages, losses, claims, causes of action, suits, demands, costs, complaints, including those resulting from any illness, injury and/or death. I further agree that THE HEALTH WAGON’S (M7) may plead this Agreement as a full and complete defense to any suit brought in violation of this promise.

12. Severability.

I agree that, should any provision or aspect of this Agreement be found to be unenforceable, that all remaining provisions of the Agreement will remain in full force and effect.

13. Governing Law.

I agree that if there is any dispute concerning my participation in the event or the interpretation of this Agreement, any such disagreement shall be determined in accordance with the laws of the State of Virginia.

14. Entire Agreement and Modification.

The terms and conditions of this Agreement represent my complete understanding of the parties hereto with regard to my participation in the event and supersedes any previous or contemporaneous understandings I may have had with THE HEALTH WAGON’S (M7) on this subject, whether written or oral, and cannot be changed or amended in any way without the written concurrence of both THE HEALTH WAGON’S (M7) and me.

15. Independent Analysis and Binding Authority.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I FURTHER ACKNOWLEDGE AND AGREE THAT I HAVE HAD AN OPPORTUNITY TO CONSULT WITH COUNSEL OF MY CHOICE PRIOR TO EXECUTING THIS AGREEMENT. I ACKNOWLEDGE AND AGREE THAT THIS AGREEMENT SHALL BE BINDING UPON MY SURVIVORS, HEIRS, SUCCESSORS, AND ASSIGNS. I AM AWARE THAT THIS AGREEMENT IS A RELEASE OF LIABILITY, INCLUDING BUT NOT LIMITED TO, LIABILITY FOR NEGLIGENCE, AND A HOLD HARMLESS AGREEMENT, AND I SIGN IT OF MY OWN FREE WILL.

17. Electronic Signature.

Electronic and digital signatures are enforceable under Federal Law. This Agreement may be executed by electronic transmission, and any such electronic signature will constitute an original signature for all purposes. You understand and agree that your eSignature executed in conjunction with the electronic submission of your application will be legally binding and such transaction will be considered authorized by you.

18. Assurances and Consent.

I HAVE READ ALL OF THE ABOVE INFORMATION AND CONSENT TO ALL OF THE FOREGOING PROVISIONS.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY AND PARTICIPATION AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS RELEASE AND WAIVER OF LIABILITY AND PARTICIPATION AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASES. I AM OVER THE AGE OF EIGHTEEN (18) YEARS AND AM COMPETENT TO EXECUTE THIS RELEASE AND WAIVER OF LIABILITY AND PARTICIPATION AGREEMENT.

Sign in the space below:
Please use your mouse to sign on a PC or use your mobile device touch screen
 
Thank you for registering as a volunteer. Upon clicking the SAVE AND SUBMIT button, you will be emailed a confirmation of your registration/updates.
   


        
       
   
       
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