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Waiver
Who is this registration for?
Please provide a name and email address for a parent or guardian, they will need to sign off for you.
Parent/guardian first name:
Parent/guardian email:
P.O. Box 6166
Key West, FL 33041-6166
(305) 293-8424 (305) 293-8542 (fax) www.KeysHealthyStart.org
CONFIDENTIALITY OF CLIENT INFORMATION
By signing below, the signatory understands and is bound to abide by all the per nent confiden ality laws in the performance of their responsibili es or contract with the Florida Keys Healthy Start Coali on, Inc. All health records are confiden al, with access governed by state and federal laws. Confiden al informa on includes, but
outside the agency, except in the performance of referrals for client care.
I have read the policies on confiden ality. I understand the seriousness and importance of confiden ality and agree to abide by the above policy and per nent confiden ality laws.
________________________________________ ___________________
Employee/Volunteer/Contractor Date
P.O. Box 6166
Key West, FL 33041-6166
(305) 293-8424 (305) 293-8542 (fax) www.KeysHealthyStart.org
CONFIDENTIALITY OF CLIENT INFORMATION
By signing below, the signatory understands and is bound to abide by all the per nent confiden ality laws in the performance of their responsibili es or contract with the Florida Keys Healthy Start Coali on, Inc. All health records are confiden al, with access governed by state and federal laws. Confiden al informa on includes, but
outside the agency, except in the performance of referrals for client care.
I have read the policies on confiden ality. I understand the seriousness and importance of confiden ality and agree to abide by the above policy and per nent confiden ality laws.
________________________________________ ___________________
Employee/Volunteer/Contractor Date
Check here to show you accept the terms stated above for yourself.
VOLUNTEER AGREEMENT AND RELEASE FROM LIABILITY
1. I, , agree to work for Florida Keys Healthy Start Coalition as a volunteer on
on/from to .
2. As a volunteer, I understand that I control the dates and times when I do the work and that Florida Keys Healthy Start Coalition is not responsible for scheduling my volunteer work. I also understand that I will not be compensated for any time spent volunteering, nor am I entitled to benefits, including employment insurance benefits upon the termination of this agreement or as a result of this service.
3. I am aware that participation as a volunteer may require periods of standing, lifting and carrying up to 40 pounds and will require the exercise of reasonable care to avoid injury. I am voluntarily participating in this activity with knowledge of the hazards and potential dangers involved, and agree to accept any and all risks of personal injury and property damage.
4. As consideration for volunteering for Florida Keys Healthy Start Coalition, I hereby agree that I, and my assignees, heirs, guardians, and legal representatives, will not make a claim against or sue Florida Keys Healthy Start Coalition or its employees, agents or contractors for injury or damage resulting from the negligence, whether active or passive, or other acts, however caused, by any of its officers, employees, agents, or contractors of Florida Keys Healthy Start Coalition as a result of my volunteering. I HEREBY RELEASE AND DISCHARGE FLORIDA KEYS HEALTHY START COALITION AND ITS OFFICERS, EMPLOYEES, AGENTS AND CONTRACTORS FROM ALL ACTIONS, CLAIMS, OR DEMANDS THAT I, MY HEIRS, GUARDIANS, AND LEGAL REPRESENTATIVES NOW HAVE, OR MAY HAVE IN THE FUTURE, FOR INJURY OR DAMAGE RESULTING FROM MY PARTICIPATION IN THE PROJECT.
5. I UNDERSTAND THAT IF I AM INJURED IN THE COURSE OF THE PROJECT, I AM NOT COVERED BY FLORIDA KEYS HEALTHY START COALITION’S WORKERS’ COMPENSATION PROGRAM. I authorize Florida Keys Healthy Start Coalition to seek emergency medical treatment on my behalf in case of injury, accident or illness to me arising from my involvement as a volunteer. I understand that I will be responsible for medical costs incurred by such accident, illness or injury.
6. I agree and understand that injuries or losses to others, such as co-workers or the person(s) being helped, may occur as a result of my negligent or intentional acts during volunteer service, and that to avoid such harm, I must exercise care and act responsibly in serving others.
7. If any injury or loss to another does occur due to my intentional actions or due to my negligent actions arising outside of the scope of my volunteer activities, I will accept the liability for and repair, or make reparations for, the harm done
8. I understand that the materials and tools provided by Florida Keys Healthy Start Coalition are and remain the property of Florida Keys Healthy Start Coalition, and I agree to return these tools and any remaining materials to Florida Keys Healthy Start Coalition at the end of my volunteer service.
9. I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.
I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND SIGN IT OF MY OWN FREE WILL.
Date Volunteer Signature Printed Name
Date FKHSC Representative Signature Printed Name
If volunteer is under 18 years of age, parent or guardian must read and sign the following:
This release, its significance, and assumption of risk have been explained to and are understood by the minor.
Date Parent or Guardian Signature Printed Name
