Volunteer Application Form

PERSONAL INFORMATION
Name
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Month
Day
Year
Phone*
Email*
Preferred Method of Contact
- Text
- Phone
- Email
Driver's License Photo Upload
Max. file size: 2 MB.
Car Insurance Photo Upload
Max. file size: 2 MB.

Training Materials, HIPAA and Confidentiality Acknowledgement
LifeCare Alliance Volunteer Training Materials are located at https://www.lifecarealliance.org/volunteer/documents/.
I recognize that I have access to this material, which includes the volunteer orientation slide show, HIPAA training outline, community safety policies, code of ethics, and Meals-on-Wheels temperature check policies. I acknowledge that is my responsibility to read and follow these guidelines set forth in the policy. If I would like additional training or if I would like hardcopies of materials, I can submit this request via email to volunteer@lifecarealliance.org or by calling the team at 614-444-6325.

HIPAA: I have read and reviewed the LifeCare Alliance HIPAA Training Outline. This training includes information on the following topics:
- HIPAA definition
- HIPAA benefits
- What is a covered entity (CE)
- Protected Health Information (PHI)
- How PHI can be used / disclosed
- Minimum Necessary Standard
- Sharing Client Information
- LifeCare Alliance Privacy Officer
- Patient Privacy Rights
- LifeCare Alliance Duties
Statement of Confidentiality: I understand that all aspects of the delivery of client services and the business affairs of the agency are not to be discussed with anyone inside or outside the organization, except when required in the usual course of my work. Confidential information includes information about our clients, their families, home environment, medical records, waiting lists, source of client payment, agency financial or business operations, or information about any employee of the agency.

I confirm that I will not put confidential or identifying client information in any electronic or text message. If this information must be communicated to LifeCare Alliance staff, it will be shared via fax or phone call.

I understand that failure to comply with this confidentiality policy may result in termination of my volunteer service.
Acknowledgement*
- I agree to the terms outlined in the Training Materials, HIPAA and Confidentiality Acknowledgement above.
Electronic Signature*
Date*

Volunteer Release and Waiver of Liability Form
This Release and Waiver of Liability (the “release”) executed on the date indicated below by the volunteer candidate below (“Volunteer”) releases LifeCare Alliance, a non-profit corporation organized and existing under the laws of the State of Ohio and each of its directors, officers, employees, and agents. The Volunteer desires to provide volunteer services for LifeCare Alliance and engage in activities related to serving as a volunteer which may involve driving, entering the home of a client, physical labor, and other activities.

Volunteer understands the scope of Volunteer’s relationship with LifeCare Alliance is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; that LifeCare Alliance 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, illness, or vehicle damage as a result of Volunteer’s services to LifeCare Alliance.
1. Waiver and Release: I, Volunteer, release and forever discharge and hold harmless LifeCare Alliance and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the services I provide to LifeCare Alliance. I understand and acknowledge that this Release discharges LifeCare Alliance from any liability or claim that I may have against LifeCare Alliance with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to LifeCare Alliance or occurring while I am providing volunteer service.
2. Insurance: I understand that LifeCare Alliance does not assume any responsibility for or obligation to provide me with the financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any nature in the event of my injury, illness, death or damage to my property. I expressly waive any such claim for compensation or liability on the part of LifeCare Alliance.
3. Medical Treatment: I hereby release and forever discharge LifeCare Alliance 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 LifeCare Alliance.
4. Assumption of Risk: I understand that the services I provide to LifeCare Alliance may include activities that may be hazardous to me including, but not limited to, driving, delivering products, entering the home of a client, physical labor involving inherently dangerous activities. As a volunteer, I hereby expressly assume the risk of injury or harm from these activities and release LifeCare Alliance from all liability for injury, illness, death or property damage resulting from services I provide as a volunteer or occurring while I am providing volunteer services.
5. Drug Free Workplace Policy: I will follow the LifeCare Alliance Drug Free Workplace Policy. Volunteers who are under the influence while volunteering will be released from their volunteer position.
6. Releases: I grant and convey to LifeCare Alliance, all right, title, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by LifeCare Alliance in connection with my providing volunteer services to LifeCare Alliance.
7. 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 Ohio and that this Release shall be governed by and interpreted in accordance with the laws of the State of Ohio. 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 below, I express my full understanding and intent to enter into this Release and Waiver of Liability as set forth above and willingly and voluntarily.
Acknowledgement*
- I agree to the terms outlined in the Volunteer Release and Waiver of Liability Form above.
Electronic Signature*
Parent/Guardian Electronic Signature (if volunteer is under the age of 18)
Date*
Comments
This field is for validation purposes and should be left unchanged.

Volunteer

A person under the age of 18 may participate in volunteer activities only when accompanied by a parent/guardian.

From the information provided on this application, a criminal background check will be processed.

If you drive as a volunteer, we are required to obtain a photocopy of your driver’s license and auto insurance.

Step 1 of 5

PERSONAL INFORMATION

PERSONAL INFORMATION

VOLUNTEER PREFERENCES

Availability

Training Materials, HIPAA and Confidentiality Acknowledgement

LifeCare Alliance Volunteer Training Materials are located at https://www.lifecarealliance.org/volunteer/documents/.

Volunteer Release and Waiver of Liability Form

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