Volunteer Form: HIPAA/PHI/Liability/Security Release

COVID VACCINE CLINIC VOLUNTEER FORM

Indemnification, Maintenance of Security, Privacy of PHI Agreement, Hold Harmless, Liability Waiver
Contact Information
Name*

First NameLast Name
Cell Phone Number*
Please enter a phone number we can text message you on.
Email*
John.Smith@gmail.com
Emergency Contact*

First NameLast Name
Relation to Volunteer*
Emergency Contact Phone Number*
Please enter a valid phone number.
Volunteer Interest

What you are interested in / what your background will help you volunteer as.
Volunteer Interest *
If you are a medical volunteer, please email an active copy of your medical license to skippackvolunteers@gmail.com.
What size T-Shirt do you wear?*
Volunteer Release and Waiver of Liability
This Release and Waiver of Liability (the “release”) executed on Date by ("Volunteer") releases Yogikrupa Health, LLC DBA Skippack Pharmacy, ("Pharmacy") an LLC organized and existing under the laws of the State of Pennsylvania and each of its directors, officers, employees, and agents. The Volunteer desires to provide volunteer services for Pharmacy and engage in activities related to serving as a volunteer.

Volunteer understands that the scope of Volunteer’s relationship with Pharmacy is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; that Pharmacy will not provide any benefits traditionally associated with employment to Volunteer; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer’s services to Pharmacy.

1. Waiver and Release: I, the Volunteer, release and forever discharge and hold harmless Pharmacy and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to Pharmacy. I understand and acknowledge that this Release discharges Pharmacy from any liability or claim that I may have against Pharmacy with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to Nonprofit or occurring while I am providing volunteer services.

2. Insurance: Further I understand that Pharmacy does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability beyond what may be offered freely by Pharmacy in the event of injury or medical expenses incurred by me.

3. Medical Treatment: I hereby Release and forever discharge Pharmacy from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with Pharmacy.

4. Photographic Release: I grant and convey to Pharmacy all right, title, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by Pharmacy in connection with my providing volunteer services to Pharmacy

5. Other: As a volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Pennsylvania and that this Release shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

By signing electronically, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.
First Name* Last Name* , hereinafter referred to as “INDIVIDUAL,” agree that Skippack Pharmacy is providing a volunteer experience for the individual. The individual participant is not an employee, agent, servant, or subcontractor of the pharmacy.
First Name* Last Name*, hereinafter referred to as “INDIVIDUAL,” hereby agrees to accept all responsibility and liability of the individual and agrees to indemnify and hold harmless Skippack Pharmacy on all actions.
I, First Name* Last Name* the undersigned, hereby agrees to indemnify and holds harmless Skippack Pharmacy, for any and all injuries and liabilities, sustained and/or incurred, by my participation in this volunteer event.
Maintenance of Security and Privacy of PHI
First Name* Last Name* , hereinafter referred to as “INDIVIDUAL,” hereby agrees to maintain the security and privacy of all protected health information (PHI) in a manner consistent with state and federal laws and regulations, including HIPAA, and all other applicable law. Individual further agrees not to use or disclose PHI except as expressly permitted by Skippack Pharmacy, applicable law, or as Skippack Pharmacy may direct in writing. Individual further agrees to use appropriate safeguards to prevent use or disclosure of PHI not permitted as provided herein.
Signature

Clear
I acknowledge the HIPAA training program and its guidelines and will comply with this policy
Date Signed*

MonthDayYear
Date
Volunteer Position*
If you are not sure what department or position you will be volunteering for, put GENERAL VOLUNTEER
Should be Empty:

COVID VACCINE CLINIC VOLUNTEER FORM

Contact Information

Volunteer Interest

Volunteer Release and Waiver of Liability

Maintenance of Security and Privacy of PHI