Spring 2018 Clinician Application.doc

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Is there anything else you think we should know about the applicant?____________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Would you recommend that the application be offered a position as a head clinician?: ___ Yes ___ No Reference’s Signature:________________________________ Date:_____________________________
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Spring 2018 PETE’s PALs Clinician Application Packet 9 TECHNOLOGY INFORMATION & RELEASE FORM SPRING 2018 To PETE’s PALs Clinicians: The future of the PETE’s PALs Program is due in part to successful promotion by our participants and families. We are therefore requesting your assistance by granting us permission to use any photographs, videotape or audio tape for our publications, videos or web pages. Please review and sign the form below if you will consent to our use of the photographs, videotapes or audio tapes. Thank you for your assistance. PHOTOGRAPHY/ VIDEO Date: __________________________ I hereby authorize and consent to the use and reproduction by the PETE’s PALs Program at Faith Community Ministries, of any and all photographs, video tape recordings, or audio tape recordings in which I appear. I understand that I am not to receive payment for the photographs, video tape recordings, or audio tape recordings, and that the photographs, video tape recordings or audio tape recordings will not discredit or distort my person in any way. All negatives and positives, and tapes, together with the prints shall be solely the property of the PETE’s PALs Program. Clinician’s Name: __________________________________________ Clinician’s Signature:________________________________________
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Spring 2018 PETE’s PALs Clinician Application Packet 10 PETE’s PALs Statement of Confidentiality As a participant in the PETE’s PALs program, you will be given access to confidential information related to the child you are working with and his/her disability. Access to this information is essential for you to be able to work effectively with your partner. However, it is also imperative that this information not be shared with anyone outside of the PETE’s PALs program. Such disclosure could be damaging to the child and/or his family. As a result, we ask that you read and sign this confidentiality statement in order to confirm that you understand the confidential nature of the information that you will receive as well the important of not sharing it outside of the PETE’s PALs program. Should you have any questions about this confidentiality statement, please contact Seairah ([email protected]) or Josie ( [email protected]) . I, (name, please print) __________________________________________________________, hereby state that I will not reveal any of the children’s (or related family members’) personal information with whom I work with throughout the duration of PETE’s PALs. I am hereby stating that I understand that all personal information including, but not limited to, the child’s health, condition of disability, and severity of disability is confidential unless otherwise specified. This information is to be shared and used solely for the purpose of the PETE’s PALs program, and should therefore not otherwise be discussed nor disclosed with anyone or in any nature outside of the program. If I am unsure as to what information may or may not be shared outside of PETE’s PALs, I will ask my Head Clinician or any member of the PETE’s PALs Administrative Team after first consulting my clinician journal and before disclosing any of the information in question. Clinician’s Name____________________________________ Clinician’s Signature________________________________ Date______________
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