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I certify that all information in this application is true and complete. I understand that any false information or
omission may disqualify me from further consideration for volunteer service and may result in my dismissal, if
discovered, at a later date.
I understand, in consideration of my application, a background investigation will be conducted. I further understand
that the investigation may include a reference check, a criminal background check, a sex offender registry check,
and driving record check.
The purpose of this release, waiver and confidentiality agreement is to protect the safety, well-being, and rights of
all volunteers, staff, agents, partners, supporters, clients, and stakeholders of Ada Jenkins Center. Everyone who
volunteers with Ada Jenkins Center is required to sign this agreement prior to beginning service with the
organization. Please carefully read and fill-in information where necessary on the following agreement before
Waiver and Release: I, the Volunteer or Guardian, do hereby release and forever discharge and hold harmless Ada
Jenkins Center and its successors, Board of Directors, partners, sponsors, employees, agents and other volunteers,
and assigns from any all liability, claims and demands of whatever kind or nature, either in law or in equity, which
arise or may hereafter arise from Volunteer’s work for Ada Jenkins Center.
I understand that this Release discharges Ada Jenkins Center from any liability or claim that the Volunteer and/or
Guardian may have against Ada Jenkins Center with respect to any bodily injury, personal injury, illness, death or
property damage that may result from Volunteer’s work for Ada Jenkins Center, whether caused by the negligence
of Ada Jenkins Center or its officers, directors, employees, or agents or otherwise. I also understand that Ada
Jenkins Center 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 injury or illness.
Confidentiality: I do hereby understand and acknowledge that during my tenure as a volunteer with Ada Jenkins
Center, I may have access to Confidential Information not generally known to the public concerning the business of
Ada Jenkins Center its client-partners. I do hereby agree that during my tenure as a volunteer with Ada Jenkins
Center and all times thereafter, I will hold Ada Jenkins Center Confidential Information in strict confidence, and will
not disclose or use such information outside the scope of my volunteer service with Ada Jenkins Center, or without
Ada Jenkins Center’s prior authorization. For purposes of this Agreement, “Confidential Information” includes, but
is not limited to, information regarding projects and potential projects, organizational practices, donors and potential
donors, client-partners, methodologies, management philosophy, and information concerning Ada Jenkins Center
employees and volunteers. I further agree that I will immediately return all Ada Jenkins Center Confidential
Information at the end of my tenure as a volunteer, or whenever requested by Ada Jenkins Center. I understand that
violation of this policy could result in the agency’s refusal to support me in the event of legal action, will lead to
disciplinary action, up to and including termination of my service with Ada Jenkins Center and conviction by fines
or by imprisonment or by both.
Volunteer Terms: I understand that the work for Ada Jenkins Center may include activities that may be hazardous
to the Volunteer, including but not limited to, construction, loading and unloading and transportation to and from the
work sites (including pickup and delivery of donations and transporting client-partners if applicable). I agree to
abide by the Ada Jenkins Center’s policies and procedures. I understand the Ada Jenkins Center
does not provide any health benefits (i.e. medical, dental, disability insurance, workers compensation, etc.) or any
accident insurance for any Volunteer; it is the responsibility of the Volunteer and/or Guardian to provide this
coverage. If, in the future, I become a client-partner I agree to notify my case manager of my volunteer role at The Center.
Background Certification: I certify that all of the information provided is true. Because the Ada Jenkins Center
strives for a safe environment for children and adults, I understand that the Ada Jenkins Center may order a criminal
history and sexual offender check, based on the program area for which I and/or the minor is volunteering, and I
authorize this investigation. Volunteers will be notified and asked to authorize a background check prior to running
Medical Treatment: I give permission for Ada Jenkins Center representatives to provide or arrange for emergency
care for me or the minor, and to arrange for transport to an emergency center for treatment. I consent to medical
treatment deemed immediately necessary or advisable by a physician if I am unable to act on mine and/or the
I do hereby release and forever discharge Ada Jenkins Center from any claim whatsoever that arises or may
hereafter arise on account of any first aid, treatment or service rendered in connection with the volunteer work for
Ada Jenkins Center or with the decision by any representative or agent of Ada Jenkins Center to exercise the power
to consent to medical or dental treatment as such power may be granted and authorized in the Parental Authorization
for Treatment of a myself and/or minor. Each Volunteer is expected and encouraged to obtain his or her own
medical or health insurance coverage.
Property Loss: I understand the Ada Jenkins Center is not responsible for my personal property lost, damaged or
stolen while participating in Ada Jenkins Center volunteer activities.
Photograph Release: I do hereby: consent that my and/or the minor’s photograph may be taken and image digitally
recorded while engaged in work for Ada Jenkins Center and do hereby grant and convey unto the Ada Jenkins
Center all right, title and interest in any and all photographic images, video, artwork, writing, or audio recordings
made by the Ada Jenkins Center during the Volunteer’s work for Ada Jenkins Center, including but not limited to,
proceeds or other benefits derived from such photographs, images, writing or recordings.
By entering and submitting this form you are signing this documenting. Submission of this form does not guarantee you a volunteer position with the Ada Jenkins Center. You will be contacted within one week of submission with a date for the next Volunteer Training session. You must RSVP in order to reserve your space in the Training.
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