Volunteer Registration & Consent
STEP 1Email & Password
STEP 2Home Address
STEP 3Family Members
STEP 5Confirm & Submit
1. Enter Email & Password
We ask for an email/password so we can set up an account for you that you can log into later.
2. Enter Home Address
3. Add Family Members
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. I affirm that the facts set forth in this application are true and complete.
I desire to volunteer for ITK and agree to perform volunteer activities solely for my personal purposes, public service, or religious or humanitarian reasons, without promise, expectation, or receipt of compensation for my volunteer work. I agree that I will not be paid nor receive any insurance, including workers' compensation insurance, unemployment compensation, or any other benefits, compensation, or contributions.
I understand that any and all forms of harassment are prohibited. I also understand that ITK's acceptance of my volunteer services is conditioned on my acknowledgement of and agreement to the terms of the ITK General Policy, the ITK Waiver, and the HIPAA Information Sheet. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
This Volunteer Agreement (the "Agreement"), dated as of (the "Effective Date"), is between Integrative Touch for Kids ("ITK"), an Arizona nonprofit corporation, on behalf of itself, its agents, employees, others acting on behalf of ITK, and successors and assigns (collectively referred to herein as the "ITK Group"), and (the "Volunteer"). ITK and the Volunteer are sometimes referred herein as the "Parties" and each as a "Party."Agreements
In consideration for the opportunity to volunteer for and on behalf of ITK, the Volunteer agrees as follows:
- Liability Release. I acknowledge and agree that I participate willingly and voluntarily in providing volunteer services and assume full responsibility for personal injury, accidents, or illness, including death or disability, and for damage to or loss of personal property while providing volunteer services. I, my heirs, personal representatives, or assigns, that I now or hereafter have or may have, hereby release, forever discharge (and covenant not to sue), and hold harmless to the full extent permitted by law, the ITK Group from any and all claims, demands, obligations, damages, penalties, costs, actions, causes of action, or suits, of any kind or nature whatsoever, either in law or in equity, which arise or may hereafter arise in connection with my volunteer work for or on behalf of ITK (collectively, the "Claims"). I understand and acknowledge that the foregoing releases and discharges the ITK Group from any liability or Claims that I, my heirs, personal representatives, or assigns, now or hereafter have or may have against the ITK Group with respect to personal injury, accidents, illness, including death or disability, or property loss or damage that may result from my participation on the ITK work site or otherwise from my volunteer work with the ITK Group. I also understand that the ITK Group does not assume any responsibility for or obligation to provide financial assistance or other assistance, including, but not limited to, medical, health, or disability insurance, in the event of personal injury, accidents, illness, including death or disability, or property loss or damage.
- Insurance. I represent and warrant to the ITK Group that I have appropriate insurance coverage that would cover me in the event I sustain any bodily injury, personal injury, illness, death, disability, or property loss or damage that may result from my participation on the ITK work site or otherwise from my volunteer work for or on behalf of ITK. I understand that ITK does not provide any insurance coverage for me, and I expressly waive any claim for compensation from or indemnity by the ITK Group in the event of such injury or medical expense. My representation and warranty shall survive and continue after the termination or expiration of this Agreement and my volunteer relationship with the ITK Group.
- Medical Treatment. I hereby release and forever discharge the ITK Group from any Claims which arise or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my volunteer relationship with ITK.
- Assumption of the Risk. I understand that my volunteer activities for and on behalf of ITK may include activities that may be hazardous to me, including, but not limited to, local transportation to and from the ITK work sites. I hereby expressly and specifically assume the risk of injury or harm resulting from my participation in these activities and in connection with my volunteer work for or on behalf of ITK.
- Assignment of Rights. I expressly acknowledge and agree that all writings, works of authorship, technology, inventions, discoveries, ideas, and other work product of any nature whatsoever, that are created, prepared, produced, authored, edited, amended, conceived, or reduced to practice by me individually or jointly with others during my volunteer relationship with the ITK Group and relating in any way to the business or contemplated business, research, or development of ITK, and all printed, physical, and electronic copies, all improvements, rights, and claims related to the foregoing, and other tangible embodiments thereof (collectively, the "Work Product") shall be the sole and exclusive property of ITK. I acknowledge and agree that, to the extent permitted by law, all of the Work Product consisting of copyrightable subject matter is "work made for hire" as defined in the Copyright Act of 1976, 17 U.S.C. § 101 et seq. (the "Copyrights"), and such Copyrights are therefore owned by ITK. To the extent that the foregoing does not apply, I hereby irrevocably assign to ITK my entire right, title, and interest in and to all Work Product and Copyrights therein, including the right to sue, counterclaim, and recover for all past, present, and future infringement, misappropriation, or dilution thereof, and all rights corresponding thereto throughout the world and will take all necessary steps to help ITK accomplish any such assignment. To the extent any Copyrights are assigned under this Agreement, I hereby irrevocably waive, to the extent permitted by applicable law, any and all claims that I now or hereafter may have in any jurisdiction to all rights of paternity, integrity, disclosure, and withdrawal, and any other rights that may be known as "moral rights" with respect to all Work Product and all Copyrights therein.
- Confidentiality. I shall hold and maintain as confidential
all non-public information received by me in connection with my volunteering
activities ("Confidential Information"). All Confidential Information shall be
treated by me as strictly confidential and shall not be disclosed, voluntarily or
involuntarily, or otherwise made available to a non-party without the prior
express written permission from ITK, or unless otherwise authorized or required
by law. Notwithstanding the foregoing, Confidential Information shall not include
- is generally known to the public at the time of disclosure or becomes generally known through no wrongful act on the part of myself;
- is in my possession at the time of disclosure;
- becomes known to me through disclosure by sources having the legal right to disclose such information; or
- is independently developed by me without reference to or reliance upon any confidential information.
- Governing Law, Jurisdiction, and Venue. This Agreement, for all purposes, shall be construed in accordance with the laws of Arizona without regard to conflicts-of-law principles. Any action or proceeding by either Party to enforce this Agreement shall be brought only in any state or federal court located in the state of Arizona, county of Pima. The Parties hereby irrevocably submit to the exclusive jurisdiction of such courts and waive the defense of inconvenient forum to the maintenance of such action or proceeding in such venue.
- Entire Agreement; Modification and Waiver. Unless specifically provided herein, this Agreement contains all the understandings and representations between the Parties pertaining to the subject matter hereof and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. No provision of this Agreement may be amended or modified unless such amendment or modification is agreed to in writing and signed by the Parties. No waiver by either of the Parties of any breach by the other Party hereto of any condition or provision of this Agreement to be performed by the other Party hereto shall be deemed a waiver of any similar or dissimilar provision or condition at the time or any prior or subsequent time, nor shall the failure of or delay by either of the Parties in exercising any right, power, or privilege hereunder operate as a waiver thereof to preclude any other or further exercise thereof or the exercise of any other such right, power, or privilege.
- Severability. Should any provision(s) of this Agreement be held to be invalid, illegal, or unenforceable in any respect by any court of competent jurisdiction, the invalidity, illegality, or unenforceability of such provision(s) shall not affect any other provisions of this Agreement, which shall continue to be enforceable, and this Agreement shall be construed as if such invalid, illegal, or unenforceable provision(s) had not been set forth herein.
HIPAA, which stands for the American Health Insurance Portability and Accountability Act, is a set of rules to be followed by doctors, hospitals, and other health care providers. HIPAA took effect on April 14th, 2006. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet consistent standards with regard to documentation, handling and privacy.
In addition, HIPAA requires that all patients be able to access their own medical records, correct errors or omissions, and be informed how personal information is shared and used. Other provisions involve notification of privacy procedure to the patient.
HIPAA Privacy Rule
Title II of HIPAA defines numerous offenses relating to health care and sets civil and criminal penalties for them. The HIPAA Privacy Rule Mandates the Protection and Privacy of all health information. This rule specifically defines the authorized uses and disclosures of "individually- identifiable" health information. The HIPAA Privacy Rule regulates the use and disclosure of certain information held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.) It establishes regulations for the use and disclosure of Protected Health Information (HI). PHI is any information held by a covered entity which concerns health status, provision of health care or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of an Individual's medical record or payment history.
For more information about HIPAA please visit http://www.hhs.gov/ocr/privacy/index.html
In consideration of my participation, and/or the participation of my minor children listed below, in one or more programs of Integrative Touch For Kids ("ITK"), I (on behalf of myself and my minor children listed below) hereby grant ITK permission to use my likeness and the likeness of my minor children listed below in all photographs, videos, or other digital media (collectively "Photos/Videos") in any and all of its publications, including (without limitation) web-based publications, without payment or other consideration. ITK shall also have the absolute right to copyright, publish, use, sell or assign any and all Photos/Videos of me and/or my minor children listed below (including, without limitation, photographic portraits or pictures, television spots, movie films, video tapes, and/or sound recordings) made in connection with my participation, and/or the participation of my minor children listed below, in ITK programs.
I understand and agree (on behalf of myself and my minor children listed below) that all Photos/Videos will become the property of ITK. I agree (on behalf of myself and my minor children listed below) that neither I nor my minor children listed below shall own or claim rights to such Photos/Videos, and I (on behalf of myself and my minor children listed below) waive any right to royalties or other compensation arising or related to the use of the Photos/Videos. I hereby irrevocably authorize (on behalf of myself and my minor children listed below) ITK to edit, alter, copy, exhibit, publish, or distribute these Photos/Videos for any lawful purpose. In addition, I waive (on behalf of myself and my minor children listed below) any right to inspect or approve the finished product wherein my likeness and/or the likeness of my minor children listed below appears. I (on behalf of myself and my minor children listed below) hereby hold harmless, release, and forever discharge (and covenant not to sue) ITK from all claims, demands, and causes of action which I and/or my minor children listed below have or may have by reason of this authorization, consent and release.