Volunteer Agreement

Thank you for your interest in volunteering for There With Care of Middle Tennessee. We value your privacy and respect your honesty. Volunteer applications are kept confidential, using the same standard of privacy as dictated by HIPAA.

Please read through the following agreement, check your acceptance, sign below and submit. We thank you for your time.
Contact Information
Name
First Last
Email*
Release Acknowledgements
VOLUNTEER ACKNOWLEDGEMENT - I understand that the service I am performing for There With Care is being provided in a volunteer capacity. I understand that I will not receive any compensation or any other benefits in connection with my volunteer position. My volunteer role may include one or more, but not all of the following: Grocery delivery, prepared meal delivery, housecleaning, laundry service, handyman service, lawn & garden care, pet care, home modifications for disability access, industrial cleaning, babysitting services (waiting room or otherwise), tutoring for siblings, special event chaperone, transportation to school or activities, transportation to hospital or treatment visits, accounting services, legal services, alternative therapies, family counseling and/or individual counseling, haircuts for the family, translating service, resource & information library, computer access. To the best of my knowledge, there is nothing that will prevent me from being able to perform the essential duties of this volunteer position, as explained to me in the volunteer training manual.*
Please select to confirm that you have read and understand the statements above.
- Yes
PHOTOGRAPHIC AND/OR VIDEO RELEASE - I hereby give my permission to be photographed and/or videotaped, and I understand that the resulting photographs may appear on the website and other marketing materials for There With Care. For valuable consideration, receipt and sufficiency of which is hereby acknowledged, but without a fee, I hereby irrevocably grant There With Care and its licensees and assigns the right to use all or any part of the photographs and/or video. I agree that I shall have no right, title, or interest in or to the photographs or any version thereof, including without limitation claims based upon right of privacy or right of publicity, or for any fees or other considerations for such use. This release shall be construed according to the laws of the State of Colorado, without regard to its choice of law provisions.*
Please select yes to give permission or no to refuse permission or photography and video use.
- Yes
- No
CONFIDENTIALITY, CONFLICT OF INTEREST AND ETHICS STATEMENT - As a volunteer of There With Care, I have an obligation to the organization I serve, to the general public, and to myself to maintain the highest standards of ethical conduct. I will not commit acts contrary to these standards nor will I condone the commission of such acts by others within the organization. I have a responsibility to: CONFIDENTIALITY * Keep confidential information confidential unless legally obligated to do otherwise. * Refrain from using or appearing to use confidential information acquired in the course of my service for unethical or illegal advantage either personally or through third parties. CONFLICT OF INTEREST - Avoid direct or indirect, actual or apparent, conflicts of interest and advise all appropriate parties of any potential conflict, if: * A There With Care representative's personal business provides goods or services to There With Care for consideration. * A friend or relative of There With Care representative provides goods or services to There With Care for consideration. * A vendor or business acquaintance with whom a There With Care representative has an outside business relationship provides goods or services to There With Care for consideration. ETHICS STATEMENT - Refrain from engaging in any activity that would prejudice my ability or the ability of others to carry out duties ethically. Refuse any gift, favor, or hospitality that would influence or would appear to influence my actions or the actions of others, for example: * A There With Care representative receives a referral fee or preferential discount, gift, or other valuable consideration from a vendor, paid promoter, fund-raising event sponsor, or any other outside party, for referring There With Care business to such party.*
Please select to confirm that you have read and understand the statements above.
- Yes
LEGAL ASSURANCE - I agree to: * Submit to a criminal background check every three years (automatically generated by There With Care at time of renewal). * Report any present, past, or future allegations of criminal activities, criminal investigations, arrests, and/or convictions involving myself. * Maintain integrity. * Refrain from violating any criminal or civil law or regulation. * Refrain from either actively or passively subverting the attainment of the There With Care’s legitimate and ethical objectives. * Refrain from engaging in or supporting any activity that would discredit There With Care. * Perform my duties in accordance with relevant laws, regulations, There With Care policies and standards. * Represent the interests of all people served by this organization and not favor special interests inside or outside the organization.*
Please select to confirm that you have read and understand the statements above.
- Yes
AUTOMOTIVE LIABILITY ASSURANCE - Participants hereby agree to provide proof of automotive liability insurance for their personal vehicle upon initial engagement within an active volunteer role which requires transporting items or persons on behalf of There With Care. The participant agrees to maintain personal liability automotive insurance on their personal vehicle throughout the length of their active service as a volunteer and will provide a valid copy of Automotive Insurance upon initial onboarding process as a volunteer and upon request.*
Please select to confirm that you have read and understand the statements above.
- Yes
RELEASE OF LIABILITY - Participants hereby release and agree to indemnify and hold There With Care harmless for, from and against any and all liability, damages and claims (“claims”) of any kind, known and unknown, which may be connected with, result from, or arise out of care or services provided by There With Care including, but not limited to, claims involving economic loss, illness or medical condition, accidental injury or death, suffered by any of the participants. Such services include without limitation the delivery of food, clothing, transportation, professional services, therapeutic support, home maintenance, and other product services. Participants hereby acknowledge that they understand such services and products may entail risk of injury or harm to the participants and agree that this risk is fully assumed by the participants.*
Please select to confirm that you have read and understand the statements above.
- Yes
Date*
MM slash DD slash YYYY
Participants agree that this Liability Release and Authorization fully and accurately expresses their understanding and has not been and shall not be modified except in writing signed by each of the Participants and There With Care. I attest and agree to be bound by the foregoing standards. I have not been party to an unethical or conflicting action that has not been previously disclosed. I also agree to report any potential future conflicts of interest or observed unethical activity of which I have become aware to the appropriate parties. I do not currently have pending against me any criminal proceedings, nor have I been placed under arrest for or been convicted of a criminal offense within the past year. I have completed and reviewed the entire Volunteer Application and attest that the information I have provided is true. Additionally, I understand and that certain volunteer positions require the completion of a criminal background check, which will be updated every three years.*
Signature
Thank You and Next Steps

We thank you for your interest in volunteering for There With Care of Middle Tennessee, supporting our mission to care for families facing critical illness. Please note, in order to protect the privacy of the families we serve and to comply with our HIPAA obligations, anyone 18 years of age or older volunteering in a capacity that involves family contact or access to family information is required to complete a criminal background check that will be automatically renewed every three years while the volunteer is actively volunteering. Once you submit this application and register for a Volunteer Training, a confirmation email will be sent containing a link to submit your background check. If you are able to cover the $15 fee for the background check, please bring cash or check to your volunteer training. Thank you.

Contact Information

Release Acknowledgements

Thank You and Next Steps