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Photo Release
I grant permission to Family & Community Services, Inc. (FCS), and it’s agents or employees, to use photographs taken of me for the use of FCS’s publications such as brochures, newsletters, magazines, display boards, electronic versions of the same publications, on the organization’s web sites, other electronic forms or media, and for distribution in other publications, electronic or otherwise, without notifying me.

I hereby waive any right to inspect or approve the finished photographs, in printed or electronic form, that may be used in conjunction with them now or in the future, whether that use is known or unknown to me. I also waive any right to royalties or other compensations arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless FCS, and its agents or employees, including any group publishing and/or distributing the finished product, in whole or in part, whether on paper or electronic form, from and against any claims, damages or liability arising from or related to the use of the photographs. This will include but is not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form (either intentionally or otherwise) that may occur or be produced in taking, processing, reduction or production of the finished product, it’s publications or distribution.

I am either 18 years of age or older and I am competent to contract in my own name. If I am under 18 years of age my parent/guardian is competent to contract on my behalf. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

Volunteer Contract Regarding Protected Health Information (PHI) As Defined by HIPPA Regulations and Applicable Laws
This form is an agreement between the volunteer and Family and Community Services, Inc. By signing this contract, you are agreeing to abide by
the following rules and requirements as an employee of Family and Community Services, Inc.:

1. As a volunteer, I will not disclose any Protected Health Information (PHI) to anyone outside
of Family and Community Services, Inc. except in the course of my employment and in compliance
with laws, regulations, and agency policies.

2. As a volunteer, I will keep private from any unauthorized person any PHI that I come into
contact with as a part of my volunteering, overheard in conversation by staff members, or seen in
a casual, inadvertent, or accidental manner.

3. As a volunteer, I understand that the protection of PHI is both required by law and required
by Family and Community Services, Inc. in its commitment to providing the highest level of
professional service to its clients.

4. As a volunteer, I agree to read the Notice of Privacy Practices (NPP) and the manual related
to Privacy Practices, and to ask for clarification if I am unsure of the meaning of any section of the
NPP or Privacy Practices manual.

5. As a volunteer, I agree that if I am unsure of how to proceed in a situation where PHI is
involved, I will consult with an appropriate agency employee, such as the privacy officer, before
proceeding with any action that might cause the privacy of PHI to be compromised.

6. As a volunteer, I agree that if I accidentally or purposely violate the privacy of PHI, I will
notify the Privacy Officer immediately. The current Privacy Officer can be reached at (330)
394-6244, extension 1149.

If you do not agree to abide by the requirements set forth in this contract, we cannot
permit you to work in any department of this agency that would put you into contact with
Protected Health Information (PHI).

If we change our Notice of Privacy Practices, and you are still a volunteer, you will receive an
updated version. The latest version will also be posted on our Web site: www.fcsserves.org

By signing below, I agree to follow all of the requirements of this contract as listed above for as
long as I am a volunteer at Family and Community Services, Inc.

HIPPA Regulations and Applicable Laws Agreement
I agreeI do not agree

Drug/Alcohol Free Workplace Policy
Any volunteer of Family & Community Services, Inc. who is found to be taking part in the unlawful
manufacturing, distribution, dispensing, possession or use of a controlled substance or alcohol
in the workplace will face disciplinary action as outlined in the agency’s Administrative Policy and
may face criminal penalties.

The consequences include immediate suspension, meeting with the Supervisor within three days
and development of a corrective plan. If the employee does not carry out the corrective action
plan as agreed, dismissal may result. However, depending upon the circumstances of the situation,
an employee may face immediate dismissal.

Any volunteer of Family & Community Services, Inc. must inform the Human Resources Director
of any criminal drug statute conviction no later than five days after such conviction. Family &
Community Services, Inc. is obligated under the United States Department of Health and Human
Services Drug Free Workplace Requirements to notify HSS of any such conviction of an employee.
When so notified by an employee of a conviction, the agency must take action within thirty days.
The actions are either to (1) terminate employment of the individual, or (2) require this employee
to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for
such purposes by a federal, state or local health, law enforcement or other appropriate agency.

In an effort to prevent or provide early recognition and treatment of drug and alcohol abuses,
Family & Community Services, Inc. carries out a drug and alcohol free awareness program to
inform volunteers about the dangers of drug and alcohol abuse in the workplace, our policy of
maintaining a drug and alcohol free workplace, available counseling and rehabilitation services,
and penalties for drug free workplace violations.

All volunteers are asked to abide by this workplace requirement. As a volunteer of Family & Community Services, Inc. I have read and agree to abide by the Drug/Alcohol Free Work Environment policy outlined above.

Drug/Alcohol Free Workplace Policy Agreement
I agreeI do not agree

Agency Confidentiality Policy
I, the volunteer filling out this application, acknowledge that an agent of
Family & Community Services, Inc. has informed me of the agency’s policies and procedures
regarding confidentiality, as well as the confidentiality laws which protect all clients of Family &
Community Services, Inc. I further acknowledge that I have received and read aforementioned
policies and procedures regarding client confidentiality.

With my signature, I am stating that I understand that Family & Community Services, Inc. expects
me to obey these policies and procedures, and the laws regarding client confidentiality, and that
information inappropriately reviewed, taken or revealed to others may result in termination from
the agency, when appropriate, and/or possible prosecution under civil or federal laws.

Agency Confidentiality Policy Agreement
I agreeI do not agree

Emergency Contact Name

Emergency Contact Phone Number

If you answered YES to the question above, please provide: 1. Nature of offense 2. # of community service hours you need to complete 3. Date service hours need to be completed by