Volunteer Form








Street Address:


City:


State:


Zip:




Preferred Phone Number:





Organization &/or Event:


Comments:





Demographic Information

Gender:


Ethnicity:


Age:


Hobbies (will help with pairings):







Volunteer Acknowledgement and Release


By signing below, I acknowledge that I am offering my services to Bosma Enterprises, on a volunteer basis. I am acting as a volunteer, not as an employee, agent, or independent contractor of Bosma Enterprises or any other person or entity. I offer my services freely and without coercion of any kind, direct or implied, from Bosma Enterprises. I further acknowledge that I am providing these services for civic, charitable, or humanitarian reasons without promise, expectation, or receipt of compensation. I understand that I am not entitled to any compensation of any kind for the time I spend serving as a volunteer for Bosma Enterprises. I agree to abide by all rules, regulations, procedures, and standards of conduct adopted by Bosma Enterprises. I further agree to act courteously at all times and to account for all property entrusted to me by Bosma Enterprises or its clients.
I agree not to sue and fully release Bosma Enterprises, its officers, agents, employees and assigns from any and all liability or responsibility, personal injury or property damages which I may suffer while performing volunteer services, including injury or damage caused by intentional acts, gross negligence, or willful or wanton conduct of any employee or representative of Bosma Enterprises or its clients. I acknowledge that Bosma Enterprises shall not have any responsibility or liability for any of my actions or omissions made while I am performing volunteer services. And, I also agree to indemnify and hold harmless Bosma Enterprises from any litigation expenses, attorney fees, loss, liability, damage or cost which may be incurred as a result of, or relating to, my volunteer services for Bosma Enterprises.
I understand that during the course of performing volunteer services for Bosma Enterprises I may come into contact with confidential information, including medical information regarding clients of Bosma Enterprises. I agree that I will not in any way publish, reveal, disclose, or cause to be published, revealed, or disclosed, any terms, information, or details of any confidential information I receive while volunteering services at Bosma Enterprises. I further agree to abide by all federal, state, and local law regulating the use and publication of any confidential information, including but not limited to the Health Insurance Portability and Accountability Act of 1996 and associated regulations regarding individually identifiable health information located at 45 C.F.R. § 164.500 et seq.
I agree that Bosma Enterprises can terminate the services offered under this Agreement at any time without notice. I have read this Agreement and fully understand its terms.


Medical Release

Date of Birth:


Social Security Number (Last 4):


Allergies:


Last Tetanus:


Hospital:


Physician 1:


Physician 1 Phone:


Physician 2:


Physician 2 Phone:


Emergency Contact 1:


Emergency Contact 1 Phone:


Emergency Contact 1 Relationship:


Emergency Contact 2:


Emergency Contact 2 Phone:


Emergency Contact 2 Relationship:


I, the undersigned, give permission to Bosma Enterprises to obtain emergency treatment and to release the information reported on this form in the event I suffer illness or accident.

Photo Release:

By signing below, I hereby authorize and consent that United Way of Central Indiana, Bosma Enterprises or the Bosma Visionary Opportunities Foundation, all not-for-profit corporations, has the right to copyright, publish, use or assign any and all photographs, television spots, movie films, video tapes and/or sound recordings or any part thereof, they have taken or made of me on this date or in which I may be included in whole or in part, whether apart from or in connection with, illustrative or written printed matter, story or news item, motion picture, television or radio spots, or for publicity, advertising or any other lawful purpose whatsoever, in conjunction with my own or a fictitious name (as indicated below), or in reproductions thereof in color or otherwise. I hereby waive any right that I may have to inspect and/or approve the finished product of the advertising copy that may be used in connection therewith of the use to which it may be applied. I hereby warrant that I am of full age and have every right to contract in my own name in the above regard, or that I am the parent or legal guardian of the minor child who is the subject of the above. I state further that I have read the above authorization and release, prior to its execution, and that I am fully familiar with the contents thereof.

Authorization:


I hereby authorize and consent the same rights as dictated above and in addition to use for a period of six months from the date of this consent for the following formats: Internal and External newsletters, Annual Reports, TV, Radio, and Print Advertisements, Social Media and Online, White Papers, Case Studies, Brochures, Outreach Materials, Grant Reports, Fundraising Campaigns, and in Public Speaking Venues.

Service Recipient Signature:


Parent/Legal Guardian Signature:




CONFIDENTIALITY AGREEMENT FOR volunteers As a material inducement for Bosma Industries for the Blind (“Bosma”) to use or continue to use my volunteer services, I hereby agree as follows: 1. Volunteer Work. I understand that I am not an employee or independent contractor for Bosma. I am solely a volunteer for Bosma. 2. Confidentiality. During the course of my volunteer work for Bosma, I have had and/or will have access to proprietary and confidential information relating to Bosma and its clients, including, but not limited to, financial information, client information, client programs, and training. During the course of my volunteer work and thereafter, I will keep secret and retain in strictest confidence all such proprietary and confidential information, and will not disclose, disseminate or use such information to my own advantage or for the advantage of any person, business or entity other than Bosma. 3. Bosma Property. All records, files, charts, reports, data, memoranda, notes, models, specifications, programs, lists (including computer-generated lists), drawings, documents, emails, equipment, and similar items relating to Bosma's business and any other proprietary data or objects I prepared or received in the course of my volunteer work with Bosma shall remain Bosma's sole and exclusive property. I agree not to remove copy or use any Bosma information for personal benefit or the benefit of any other person or business entity.
Signature: