Volunteer Agreement and Release from Liability
This release and waiver of liability (the “Release”) is given in favor of Santa Maria Community Services (“SMCS”) a 501(c)(3) organization, and its directors, officers, employees, affiliates and agents, and the heirs, executors, personal representatives, successors and assigns of each of them (“SMCS Parties”).

Volunteer desires to work as a volunteer on a SMCS project (“Project”) and to engage in the other activities related to being a volunteer. Volunteer understands that the Project may include activities that are physically and/or mentally and emotionally challenging. Volunteer does hereby freely, voluntarily and without duress, give this Release under the following terms:

Voluntary Participation
I acknowledge that I have voluntarily applied to participate in this Project. I understand that as a volunteer I will not be paid for my services. I further agree that my participation in the Project may be terminated at any time by Santa Maria Community Services (“SMCS”).

Assumption of Risks
I am aware that by participating in the project, I may be exposed to personal injury, death or damage to my property as a result of my activities, the activities of other volunteers or SMCS participants, or the conditions under which my volunteer services are performed. With knowledge of these risks, I agree to accept any and all risks of personal injury, death or damage to my property.

Release
In consideration of the opportunity afforded me to participate in the Project, I hereby agree that I, my successors, assignees, heirs, guardians and legal representatives, will not make any claim against SMCS, or any of its affiliated organizations (including local affiliates), or their officers, directors, or employees, or any suppliers of any materials or equipment that are used during the Project, any of the project volunteers or sponsors, or any service recipients participating in the project, for injury, death, or damage resulting from the act or omissions of any person or entity, however caused, arising from my participation in the Project. I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.

Media/Photographic Release
I do hereby grant and convey unto SMCS, and any of their affiliated companies, permission to use my name, statement(s) and my likeness in any and all of its publications or advertisements in print, television, online (including without limitation, its websites or pages on Facebook or other social media sites) and any other media, without compensation to me. This consent is irrevocable and is without payment. The materials will become the property of the SMCS Parties and will not be returned. I waive the right to inspect or approve anything in which my name, statement(s) or likeness appears and I waive any right to royalties or other compensation arising or related to their use.

Medical Treatment
I do hereby release and forever discharge the SMCS Parties from any claim whatsoever which arises on account of any first aid, treatment or service rendered in connection with my work on the Project.

Code of Conduct
It is expected that every volunteer will treat others with respect, courtesy, and dignity. In addition, all volunteers at any SMCS Project will be expected to:

  • Obey all local, state, and federal laws;
  • Respect local customs, culture and practice;
  • Behave in a courteous and respectful manner, refraining from language and actions contrary to SMCS’s expectations;
  • Refrain from the use of illicit drugs, and any other illegal substances according to local, state, and federal laws. These items must not be used or possessed at any time or under any circumstances and are prohibited at all times by volunteers throughout the duration of the Project. Use or possession of such substances may result in criminal prosecution;
  • Refrain from sexual harassment consisting of but not limited to, unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. These actions will not be tolerated in any manner at the project. Any reported incident of sexual harassment will result in the immediate removal from the Project and all related activities;
  • Refrain from activities that endanger self or others;
  • Respect at all times the facilities, equipment, rooms, buildings, and surroundings used throughout the project;
  • Report accidents, injuries and illnesses, and any illegal activities to Project organizers immediately;
  • Become familiar with the rules, regulations and safety guidelines issued by the manufacturer or seller of any tool, product, or material used during the course of the Project, and abide by them.

SMCS reserves the right to notify law enforcement as it deems necessary and appropriate.

Confidentiality
As a volunteer for the SMCS Project, I agree to abide by all local, state and federal laws and regulations pertaining to the security, privacy and confidentiality of medical records-medical information. I agree to review only those records that pertain to my work on a “Need to Know” basis. I agree not to read a record, insert or remove items, or make copies of all or part of a record except as a necessary and legitimate part of my work. I agree to refer all first and third party requests for information to the appropriate SMCS personnel. I further agree not to discuss with family, friends and neighbors the progress or uniqueness of a case so that identification of a SMCS participant could be readily identifiable. Should I disregard the terms of the agreement I will be subject to appropriate action and may be subject to Civil or Criminal action.

Knowing and Voluntary Execution
I have carefully read this agreement and fully understand its contents. I am aware that this is a contract and a release of liability between myself and the SMCS parties, and I sign it of my own free will. By signing this agreement, I certify that I am eighteen years of age or older, or I have obtained parental consent if I am under eighteen years of age.

 

Form Difficulties

If you have technical difficulties, you may download the form in Microsoft Word here or Adobe PDF here and then e-mail the completed form to Lynne.Rinear@santamaria-cincy.org.