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Volunteer Applicant Agreement

My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian, religious or charitable reasons.

I authorize the Hospital to investigate my volunteer application and my background and activities at any time. I agree to cooperate in such investigation(s) and authorize all persons and entities to provide information as requested by the Hospital or its agents. I further release the Hospital and all those who provide information to the Hospital from any and all claims I may have related to requests for information and disclosures of information.

I understand that neither my volunteer application nor my volunteer service at the Hospital are confidential. I authorize the Hospital to disclose or withhold disclosure of information concerning my application or volunteer services, as it deems appropriate. I release the Hospital, its employees, and representatives from any and all claims I may have related to disclosures concerning me.

I shall hold as absolutely confidential all information I may obtain directly or indirectly concerning patients, doctors or other hospital personnel and not seek to obtain confidential information from a patient or access any information that is not necessary in carrying out my duties as a volunteer.

I understand that the Volunteer Services Department reserves the right to terminate my volunteer status as a result of (a) failure to comply with Hospital policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance; or (d) any other reason as determined by the Hospital in its judgment.

I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, both on or off hospital property, or act as a runner or capper for an attorney in the solicitation of business. I shall report all known occurrences of solicitation for attorneys to the Volunteer Coordinator.

I shall not sell or attempt to sell goods or services, request contributions, or to solicit persons or sign or distribute political petitions on hospital premises, unless I receive the express authorization of the Coordinator of Volunteer Services to engage in these activities.

I shall uphold the mission, values, code of ethics and standards of the Hospital.

I understand that any information I may obtain directly or indirectly concerning patients, doctors, or other hospital personnel while I am a volunteer at Port Huron Hospital is confidential and that this confidentiality is protected and punishable under Federal Law.

I release the Hospital, its affiliates, and their Board members, employees, and representatives from any and all claims I may have on any basis whatsoever related to my volunteer application or any of my activities as a volunteer with the Hospital.

 I have read each of the above conditions and I agree to be bound by them.
Parent Name if Volunteer is under Age 18: Completed Date: