Appears in 5 contracts

Samples: Volunteer Agreement, Volunteer Agreement, Volunteer Agreement

Appears in 2 contracts

Samples: Volunteer Agreement, Volunteer Agreement

Appears in 2 contracts

Samples: Volunteer Agreement, Volunteer Agreement

Appears in 2 contracts

Samples: Volunteer Agreement, Volunteer Agreement

Appears in 1 contract

Samples: www.buildinglives.org

Authorization for Release of Protected Health Information. I authorize the following entities to disclose my health information to Habitat for Humanity International, Inc., its affiliated companies, and their officers, directors, volunteers, agents, employees and their authorized representatives (for purposes of this paragraph, collectively "Habitat"): ACE American Insurance Company, its affiliated companies, and any authorized representatives ("Company"). My health information includes any and all information relating to my health which is in the possession of Company, including but not limited to medical and dental records, medical consultations, treatments, or surgeries; psychiatric or psychological care; use of drugs or alcohol; drug prescriptions; and communicable diseases, including HIV/AIDS. I understand the health information to be disclosed includes information protected under Federal and State law, including regarding mental health, substance abuse, developmental disabilities, infectious/communicable diseases, privileged communications and genetic information. I understand that the disclosure to Habitat is for the following purposes: eligibility confirmation; claim submission facilitation; claim inquiry and dispute resolution; fraud detection; and audit and quality control services. I understand that the signing of this Authorization is voluntary and is not required to receive benefits under any Company insurance policy. . I understand that I may request a copy of this Authorization. I agree that a photographic copy of this Authorization shall be as valid as the original. I understand that this Authorization is valid for the longer of 12 months or the duration of any claim for benefits under any Company insurance policy, but in no event longer than 24 months. I understand that I may revoke this Authorization at any time by providing written notification to the Company at CHUBB North American Claims c/o CHUBB A&H Claims, Xxx Xxxxxx Xxxxxx Xx, Xxxxxxxxxx, XX. 00000. Such revocation shall not have any effect on actions that the Company and/or Habitat took in reliance on the Authorization prior to each receiving notice of the revocation.. Photographic/Recording Release. I hereby grant and convey unto Habitat for Humanity International, Inc. all right, title and interest in any and all photographs and video/audio/electronic recordings of me, including as to my name, image and voice, made by or on behalf of any of the Released Parties during my Activities with the Released Parties, including, but not limited to, the right to use such materials for any purpose and to any royalties, proceeds or other benefits derived from them. I understand that I will not have any ownership interest in or to such photographs, images and/or recordings, I have not been provided or promised any compensation to me, and I hereby waive any rights, privileges or claims based on any right of publicity, privacy, ownership or any other rights arising, relating to or resulting from the photographs, images and/or recordings. I understand and agree that this paragraph also applies to my minor child(ren) who are volunteering. Other. I expressly agree that this Release is intended to be as broad and inclusive as permitted by state law. I further agree that in the event any clause or provision of this Release is held invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining clauses or provisions of this Release, which shall continue to be enforceable. Further, a waiver of a right under this Release by a Released Party does not prevent the exercise of any other right. I have carefully considered my decision, the benefits and risks involved and hereby give my informed consent to participate in all volunteer Activities. I have read and understand this Release and Waiver of Liability, any questions of mine have been answered, and I voluntarily agree to the above provisions. It is my intent to bind my heirs, next of kin, assigns and legal representative. SIGNATURE OF VOLUNTEER 18 YEARS OR OLDER: Volunteer: Name (please print): Signature: Address: City/State/Zip: Phone: (H) (C) Date of Birth: Email: Witness: Name (please print): Signature: EMERGENCY CONTACT INFORMATION FOR VOLUNTEER OVER 18 YEARS OF AGE: Name: Relationship: Address: Phone: (H) (C) (W) Email: IMPORTANT: If the Volunteer is less than 18 years of age, all parents or guardians must (1) complete the signature section on the following page; and (2) sign one additional form: the “Parental Authorization for Treatment of, and Travel With, a Minor Child” (“Parental Authorization”) on the next following page. If the minor will be travelling outside the United States, the Parental Authorization must be notarized. If only one parent or guardian signs these forms on behalf of a Volunteer who is under 18 years of age, then the undersigned parent or guardian of the Volunteer hereby covenants, warrants, represents and agrees that he or she is executing these forms on behalf of, and as an agent for, any other individual who may be a parent or guardian of the Volunteer, that he/she is fully authorized to do so, and that by executing such Release and Parental Authorization, the undersigned is binding himself/herself, the Volunteer, and any other parent or guardian of the Volunteer, and all of their heirs, next of kin, assigns, and legal representatives to such Release and Parental Authorization. Name of Volunteer Under 18 Years Old: Name: Date of Birth: SIGNATURE OF PARENT/GUARDIAN SIGNING ON BEHALF OF THE ABOVE MINOR: I have carefully considered my decision, the benefits and risks involved and hereby give my informed consent, on behalf of the above listed minor child, for him/her to participate in all Activities as set forth in the above Volunteer Agreement, Release and Waiver of Liability, and such terms are incorporated herein. I have read and understand the above Volunteer Agreement, Release and Waiver of Liability, any questions of mine have been answered, and I voluntarily agree to all such provisions. It is my intent to bind my and the minor Volunteer's heirs, next of kin, assigns, and legal representatives. Parent/Guardian: Name (please print): Signature: Address: City/State/Zip Phone: (H) (C) E-mail: Witness: Name (please print): Signature: Parent/Guardian: Name (please print): Signature: Address: City/State/Zip Phone: (H) (C) E-mail: Witness: Name (please print): Signature: Name: Relationship: Address: City/State/Zip Phone: (H) (C) (W) Email: EMERGENCY CONTACT INFORMATION FOR THE ABOVE LISTED MINOR VOLUNTEER: Next Page IMPORTANT: If the Volunteer is less than 18 years of age, this Parental Authorization also must be signed. If the minor child will be travelling outside the United States, the Parental Authorization must be notarized. PARENTAL AUTHORIZATION FOR TREATMENT OF, AND TRAVEL WITH, A MINOR CHILD I, , am the parent or legal guardian having custody of a child who is under 18 years old and who will be volunteering with Habitat for Humanity International, Inc. or its affiliated organizations. As such parent or legal guardian, I hereby authorize and appoint , an adult in whose care the minor child has been entrusted, and any agent or employee of Habitat for Humanity International, Inc. or its affiliated organizations if necessary or appropriate, as my agent to act for me with respect to my minor child and his or her personal care, and in my name in any way I could act in person to make any and all decisions for me with respect to my child listed below (“child”): Name: Date of Birth: I consent to the use of first aid treatment for my child and the use of generic and over the counter medications and treatments as directed by manufacturer labels, to be administered by Habitat for Humanity International, Inc. or its affiliated organizations or first aid personnel. In an emergency, I understand my named agent and/or Habitat for Humanity International, Inc. or its affiliated organizations may try to contact the individual listed below as an emergency contact. If an emergency contact cannot be reached promptly, I hereby authorize the named agent above and any agent or employee of Habitat for Humanity International, Inc. or its affiliated organizations to act as an agent for me to consent to any examination, testing, x- rays, medical, dental, or surgical treatment for my child as advised by a physician, dentist or other health care provider. This includes, but is not limited to, my child’s assessment, evaluation, medical care and treatment, anesthesia, hospitalization, or other health care treatment or procedure as advised by a physician, dentist or other health care provider. I also authorize Habitat for Humanity International, Inc. or its affiliated organizations to arrange for transportation of my child as deemed necessary and appropriate in their discretion. My agent shall have the same access to my child’s medical records that I have, and is designated by me to be the child’s Personal Representative under the Health Insurance Portability and Accountability Act (HIPAA), including the right to disclose the contents to others. I authorize health care personnel and health care facilities to rely on this consent form and any health information I have provided to my named agent and/or Habitat for Humanity International, Inc. or its affiliated organizations regarding my child. I authorize and appoint my agent to travel with my minor child to [insert location], and consent for my minor child to serve as a volunteer with Habitat for Humanity International, Inc. or its affiliates. I understand my child will help construct/rehabilitate houses and participate in other activities on a voluntary basis, without compensation, as further set forth in the Volunteer Agreement, Release and Waiver of Liability, the terms of which are incorporated herein by reference. I have read and understand the above Parental Authorization for Treatment of, and Travel With, a Minor Child, any questions of mine have been answered, and I voluntarily agree to all such provisions. Parent/Guardian: Name (please print): Signature: Date: Parent/Guardian: Name (please print): Signature:

Appears in 1 contract

Samples: Volunteer Agreement

Appears in 1 contract

Samples: Volunteer Agreement

Common use of Authorization for Release of Protected Health Information Clause in Contracts