Adult Volunteer Waiver


Adult Volunteer Waiver

  • I,
  • certify that I am at least 18 years old and hereby agree to volunteer with Washington Township, Ohio (Delaware, Franklin, and Union Counties) (“the Township”). As a volunteer with the Township, I agree to hold the Township, as well as its Trustee, employees, agents, attorneys, insurers, and representatives harmless from all liability for all injury or illness to my person, or any damage, destruction, or loss of any personal property of whatever kind or character, owned by me or in my possession, while volunteering to do
  • By signing this Form, I recognize and acknowledge that I am engaging in activities that involve a risk of injury and/or death, and knowingly, voluntarily, and fully assume such risks, whether foreseeable or not reasonably foreseeable. I also understand the Township does not assume any responsibility for, or provide, financial assistance or any other assistance or benefit, including but not limited to, medical, health, or disability service in the event of any injury, illness, death, or property damages suffered by me while participating in the Volunteer Program.

    I, on behalf of my myself, as well as my spouse, heirs, executors, administrators, agents, representatives, successors, and assigns, hereby and forever waive and release the Township, as well as its Trustees, employees, agents, attorneys, insurers, and representatives, from any and all losses, liabilities, costs and expenses (including attorney fees), demands, damages, claims, and causes of action, in law or equity, whether presently known or unknown, related in any way to participating in the Volunteer Program.

    I understand and acknowledge the Township, thru its Fire Department, provides services to patients that are private and confidential and I may be exposed to this private and confidential information. I also understand and agree that I have an unconditional duty to respect and maintain the privacy of these patients. I also understand and agree that I may not, under any circumstances, take photos or videos or use social media to record events, actions, or omissions that occur during my participation in the Volunteer Program.

    I agree to allow, and grant full permission to, the Township to use any photographs, videos, or recordings of me while participating in the Volunteer Program.

    I understand and consent to the Township conducting a criminal background check. I acknowledge the Township, at its sole discretion for any reason or no reason at all, may deny or revoke my participation in the Volunteer Program.

    I, agree to carry out my obligations under this Form unconditionally in compliance with the privacy regulations pursuant to Public Law 104-191 of August 21, 1996, known as the Health Insurance Portability and Accountability Act of 1996, Subtitle F – Administrative Simplification, Sections 261, et seq., as amended ("HIPAA"), to protect the privacy of any personally identifiable protected health information ("PHI") that is collected, processed or learned as a result of my status as a volunteer with the Washington Township Fire Department.

    By signing below, I acknowledge that I have carefully read this Form, completely understand its contents, and fully agree to be bound by its terms. By electronically signing below and submitting this Waiver online through the Township website, I agree that this Waiver may be executed by electronic signature, which shall be considered as an original signature and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include a typewritten printing of my name preceded by the “/s/” designation, faxed versions of an original signature, or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.

  • For example: /s/ Jon Smith

Print Friendly, PDF & Email