Form Center

I understand that the information I have submitted will be kept confidential and provided only to representatives of the Clay County Public Health Center and its sponsoring agencies for purposes of evaluating this application. 

I do hereby give Clay County Public Health Center permission to inquire into my background, including references, employment, licensure and/ or volunteer history as part of the application review process. I further give permission to the holder of any such records to release same to the Clay County Public Health Center and its sponsoring agencies.

By checking the "I agree" box below, I give permission for my name and likeness (photographic, video, and electronic images), to be used in print or electronically published materials (including, but not limited to television, internet, and cable) as distributed by Clay County Public Health Center and / or news media.

Please read Clay County Public Health Center's Records Confidentiality Agreement. We ask that interns/students maintain the same strict standards when it comes to protecting patient/client privacy.

I, the undersigned volunteer, student or intern, have received, acknowledge that I have read, understand and agree to comply with the Confidentiality Agreement as listed in the linked document. 

I also understand that, although volunteers, students or interns, are not listed in agreement, that I am being upheld to the same standards as CCPHC employees.