Volunteer Agreement And Release From Liability (Page 2 of 2) in pdf

Volunteer Policies. I have received and reviewed the Senior Services Volunteer Manual (“Manual”), which is

incorporated herein and may be modified from time to time. I agree to abide by the rules, policies and procedures

contained within the Manual. I understand and agree that if I do not adhere to the rules and procedures set forth in the

Manual or if I fail to satisfactorily perform my volunteer assignment, I am subject to dismissal at Senior Services’ sole

discretion. Possible grounds for dismissal may include, but are not limited to: gross misconduct or insubordination;

theft or misuse of Senior Services materials; abuse or mistreatment of clients, staff, or other volunteers; failure to

abide by Senior Services policies and procedures; violation of Sections 8 or 9 of this Agreement; and failure to

satisfactorily perform assigned duties.

Driver’s License; Insurance. As a volunteer, I agree to provide proof of a valid driver’s license and current

automobile insurance. I agree to mail or deliver copies of these documents to Senior Services to be filed with this

agreement. I will maintain automobile insurance and notify my volunteer coordinator of changes. I will immediately

notify my volunteer coordinator if my driver’s license becomes restricted, suspended, revoked or expires.

Background Check; Convictions. I agree that my participation as a volunteer for Senior Services is contingent upon

satisfactory completion of a criminal background check, to be conducted at Senior Services’ expense. As a volunteer,

I will notify my volunteer coordinator of any criminal convictions or criminal charges that are pending against me or

which arise during the course of my volunteer activities with Senior Services.

Confidentiality. I understand that as a volunteer, I may be exposed to confidential information, including identifying

information and Protected Health Information (“PHI”) as defined by the Health Insurance Portability and Accountability

Act of 1996, and that Senior Services and its agents, including volunteers, are required by law and ethical

considerations to preserve and maintain the privacy of those receiving services. I agree that I will not disclose any PHI

that I may receive, except that I may disclose the minimum amount of PHI necessary to effectively complete my

volunteer assignment. I also agree to notify Senior Services immediately upon learning of any accidental or

unauthorized disclosure of PHI or other identifying information.

Abuse/Neglect. I agree that if I have a reasonable belief that someone receiving services from Senior Services has

been intentionally injured, neglected, or exploited, I will immediately notify my volunteer coordinator.

10.

Relationship of the Parties. I acknowledge that this Agreement will not be construed as constituting a relationship of

employment, agency, partnership, joint venture or any other form of legal association. Neither Party has any power to

bind the other Party or to assume or to create any obligation or responsibility on behalf of the other Party or in the

other Party’s name. I acknowledge that my role with Senior Services is strictly voluntary, and hereby waive any claim

or right to any compensation, including employment benefits, for performance of the any volunteer activities under this

Agreement.

11.

Other. The section headings contained in this Agreement are for reference purposes only and shall not affect in any

way the meaning or interpretation of this Agreement. The Parties agree that this Agreement shall be governed by the

laws of the State of Georgia, exclusive of its conflict of laws provisions. The Parties agree that any dispute that arises

in whole or in part from this Agreement shall be decided exclusively by a court of competent jurisdiction located in

Fulton County, Georgia. The parties further agree that in the event any clause or provision of this Agreement shall be

held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise

affect the remaining clauses or provisions of this Agreement, which shall continue in full force and effect. This

Agreement contains all of the terms and conditions agreed upon by the Parties and any prior agreements, promises,

or representations, written or oral, not expressly set forth in this Agreement, are of no force and effect. Any

amendment or modification to this Agreement must be made in writing and signed by the parties. Any amendment or

modification not made in this manner shall have no force or effect.

HAVE

CAREFULLY

READ

THIS

AGREEMENT

AND

FULLY

UNDERSTAND

ITS

CONTENTS.

I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND AM EXECUTING IT FREELY AND VOLUNTARILY.

Signature of Volunteer _________________________________Date____________________

Printed Name _____________________________________________________

If the volunteer is under 18 years of age, the volunteer’s parent or legal guardian must sign this agreement on behalf of

the minor volunteer.

The parent or legal guardian also acknowledges that they have explained the release, its

significance and assumption of risk to the minor as well as the rules and policies of Senior Services contained in the

volunteer manual.

Parent/Guardian Signature _____________________________Date____________________

Rev. 05/14

Volunteer Agreement And Release From Liability Page 2

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