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Date Format: MM slash DD slash YYYY
Volunteer Contact Information
Minor Volunteer Names
All information - verbal, written, or computerized - concerning donors, recipients, paid staff and volunteers will be held in the strictest confidence and shared only within the agency to the degree necessary to perform the task at hand. I understand that compliance with this policy is a condition of my participation in the Second Helpings volunteer program and that failure to maintain confidentiality will result in termination of my volunteer relationship with the agency, or other corrective action.
I hereby consent to be videotaped and/or photographed by any person designated by Second Helpings, Inc., and I hereby grant, deliver, assign and release unto Second Helpings, Inc. its successors, assigns, and its subsidiaries and affiliated corporations all of my right, title and interest in and to such material, including the verbal content, products, results and subject matter of the videotaping and photography taken of me and also the irrevocable right, authorization, and license to exhibit, publish, display, copyright, reproduce, dispose of and/or use all or any portion of the aforesaid in any lawful way whatsoever, including the right to use the same for lawful purposes in any publication or media, with or without my name or other identification. I hereby release and forever discharge Second Helpings, Inc., its successors, assigns and its subsidiaries and affiliated corporations of and from any and all claims, demands, suits, actions and/or liability, for additional compensation or otherwise, in connection with any of the forgoing. I hereby understand and acknowledge that Second Helpings, Inc. shall have and own the sole and exclusive right to commercially utilize my activities, and I shall not reproduce, sell or otherwise utilize any of the reproductions of my activities, or assist another party in doing any of the foregoing, without Second Helpings, Inc. prior written consent. I hereby waive any right that I may have to inspect or approve the finished product or the display or copy that may be used in connection therewith or the use to which it may be applied.
In consideration, and as a condition, of my acceptance by Second Helpings, Inc. as a volunteer for Second Helpings, Inc., I hereby waive, release, and hold harmless Second Helpings, Inc. and United Way of Central Indiana, its officers, directors, employees, representatives, and volunteers from any and all claims and actions related to or arising out of my volunteer activities for Second Helpings, Inc. including any injuries to me from any cause, and related to or arising from any facts or situations unknown to me at the time of my signing this release.
- Opportunities for volunteers at Second Helpings are provided without regard to religion, creed, race, national origin, financial status, age, gender, or disability.
Food Establishment Employees/Volunteers
The Indiana State Department of Health Food Establishment Regulations requires that all employees/volunteers of inspected food establishments report immediately to the person in charge if they experience any of the specified symptoms or conditions listed. The person in charge can then take appropriate action to preclude the transmission of foodborne illness.
I agree to report to my immediate supervisor:
Symptoms and pustular lesions:
- Sore throat with fever
- Lesions containing pus on the hand, wrist or exposed body parts (Such as boils and infected wounds regardless of size)
Whenever diagnosed as being ill with Norovirus, typhoid fever (Salmonella Typhi), Shigellosis (shigella spp.), Escherichia coli O156:H7 infection (E. coli O157:H7), or other EHEC/STEC infection or hepatitis A (Hepatitis A virus).
- Exposure to or suspicion of causing a confirmed outbreak of Norovirus, typhoid fever, shigellosis, E. coli O157:H7 or other EHEC/STEC infection or hepatitis A.
- A household member diagnosed with Norovirus, typhoid fever, shigellosis, illness due to E. coli O156:H7 or other EHEC/STEC or hepatitis A.
- A household member attending or working in a setting experiencing a confirmed outbreak of Norovirus, typhoid fever, shigellosis, E. coli O157:H7 or other EHEC/STEC infection or hepatitis A.
I have read (or had explained to me) and understand the requirements concerning my responsibilities under the Food Regulation and agree to comply with:
- Reporting requirements specified above involving symptoms, diagnoses and high-risk conditions specified;
- Work restrictions or exclusions that are imposed upon me; and
- Good hygienic practices.
I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority, will result in my termination as an employee/volunteer, and that I may be subject to legal action against me for violation of the law or regulations.
Type your name to electronically sign.