This is optional.
Security Background Release
Some agencies require background checks.
Please carefully read and initial the following:
Release and Waiver of Liability
By enrolling as a volunteer, I fully release and hold harmless the Volunteer Center, its directors, officers, employees, and agents from any and all liability, claims, or demands of any kind that arise or may arise from the services I provide. I also waive any claims I may have against the Volunteer Center that arise or may arise from the services I provide. I understand and acknowledge that this Release and Waiver discharges the Volunteer Center from any liability or claim I may have concerning bodily injury, illness, death or property damage that may result from the services I am providing.
I release and discharge the Volunteer Center from any claim that arises or may arise on account of any first-aid treatment or other medical services rendered to me during my tenure as a volunteer.
Automobile Insurance Statement:
I understand that if I use my personal vehicle during my volunteer service, I will arrange to keep in effect automobile insurance equal to the minimum state requirement and will inform The Volunteer Center office of any change in coverage or driver’s license status in order to qualify for the excess automobile insurance coverage.
Assumption of Risks:
As a volunteer, I hereby expressly assume the risk of injury or harm from volunteer activities and Release The Volunteer Center from all liability for injury, illness, death or property damage resulting from the services I provide as a volunteer or occurring while I am providing volunteer services.
Information Release Authorization:
I authorize the release of the information on this form to The Volunteer Center's Partner Agencies for the purpose of my volunteer placement. I understand that The Volunteer Center will not release volunteer contact information to any other third parties without my permission.
I hereby grant and convey unto The Volunteer Center all rights, title, and interest in any and all photographs, images, and video or audio recordings in connection with my providing volunteer services.
I understand that all information on this form is voluntarily supplied and may be used and disclosed in a professional manner and in good faith for the specific purpose of volunteerism only. I understand it is the policy of The Volunteer Center to regard all information (both written and verbal) pertaining to staff, volunteers and clients served as confidential. Furthermore, I understand and agree to comply with the confidentiality statement as it pertains to information I may learn or be entrusted with as a volunteer in the community.
Drug Free Statement:
The Volunteer Center is committed to providing a drug free, healthful, safe and secure work environment for employees and volunteers. Each employee and volunteer is expected and required to report to work in an appropriate mental and physical condition to perform his/her assigned duties. The Volunteer Center prohibits the use, possession or sale of illicit drugs in the workplace or when conducting agency business. The Volunteer Center requires its employees and volunteers to be free from illicit drugs and to be free from the influence of alcohol or the influence of legal drugs where the potential for impairment or unsafe job performance is indicated. I understand this policy and agree to comply with it.
Please sign below. This affirms you have read and understand the waiver and release, insurance, confidentiality, insurance and drug free statement on this form and that all above information is true to the best of your knowledge.
*I understand that as a volunteer of the Volunteer Chore Program I am a representative of VCP and will treat all clients and other volunteers with respect. I understand that while I may become friends with a client I help, that relationship has certain boundaries and I will honor those boundaries, including: staying out of my client’s legal matters, not accepting gifts from clients or giving them gifts (unless approved by VCP staff) and not accepting personal items for use from a client, like house keys, vehicle, etc.
(*This is for a volunteer’s protection as well as our clients’ protection.)
Client Confidentiality Policy - PLEASE READ CAREFULLY
Policy: Personal information about a chore client may not be disclosed by any person or
organization without the informed consent of the client.
Exception: The Volunteer Chore Program may disclose information to the Area Agency on Aging (AAA) or Department of Social and Health Services (DSHS) for purposes directly connected with the administration of their programs. Such purposes include but are not limited to: determining eligibility, providing a service to resolve client complaints, and participating in an audit.
Exception: The Volunteer Chore Program may disclose information for research, statistical, monitoring, or evaluation purposes conducted by appropriate federal agencies and DSHS. Other entities to which information may be disclosed for the preceding purposes are those agents authorized by DSHS in writing, including AAA’s and organizations and/or individuals under contract to the department.
These exceptions do not apply when federal and/or state regulations for a particular program require that informed consent be obtained.
Unless the situation is covered by the above exceptions, personal information may not be released without the informed consent of the client or his/her guardians. To meet the requirements of informed consent, the client or his/her guardian must be fully apprised of:
1. The voluntary nature of the disclosure.
2. The nature and extent of the information being released.
3. The person or organization to whom the information will be released.
4. The purposes for which the information will be used.
5. The effect, if any, on the subject, of not providing all or part of the requested information.
6. Any other facts which, under the circumstances, are necessary to the giving of intelligent
A written release must be used.
All staff (paid or unpaid) of the Volunteer Chore Program, and its’ host agency, The Volunteer Center of Whatcom County/Opportunity Council, are bound to the above policy. Program clients act in good faith, expecting their circumstances and personal matters to remain confidential, and we are obligated by law and ethics to reciprocate.
Subject to the policy and exceptions noted within this document, the following guidelines have been established in the matter of confidentiality:
1. Information and details about name-specific client situations may be discussed for program purposes only, i.e. case may be discussed in staff and supervisory meetings in order that service may be more appropriately managed.
2. The file records that are kept on clients should be used only for program purposes. Other agencies requesting the records of given clients should first obtain releases of information from the client. In no case should the records be automatically sent to another person or agency without first receiving a release of information from the client or their legal guardian.
3. Discussing the details of a client outside the program, even though names and addresses are not revealed, could also be considered a breach of confidentiality. That is, one might possibly describe in detail facts about the client and never mention who the person is or allude in any way to names or type of descriptive data, and yet, within the description, reveal enough that the listener might possibly identify the client. If client examples are used for illustrative purposes, care must be taken in sufficiently altering the circumstances of the example to assure that client confidentiality is maintained.
4. The fact that a client situation has been made public by other means (including the news media) does not alter the fact that this person still has confidentiality privileges within the program itself.
The following oath will be signed by each staff (paid and unpaid) of the Volunteer Center of Whatcom County/Opportunity Council and by each staff (paid and unpaid) of the Volunteer Chore Program. This form will be retained in the office of the Volunteer Center of Whatcom County/Opportunity Council.
BY SIGNING BELOW I UNDERSTAND AND AGREE TO THE ABOVE POLICY AND AM AWARE THAT ANY BREACH OF CONFIDENTIALITY IS GROUNDS FOR IMMEDIATE ACTION BY MY SUPERVISOR.
I attest that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.
To the best of my knowledge and belief, my record may contain one or more of the foregoing disqualifying acts or offenses.
Photo ID and Insurance Card