Schreiber Center Volunteer Application: Court-Ordered Community Service

In consideration of being allowed to participate as a volunteer in the Schreiber Center for Pediatric Development ("SCPD")and all related events and activities ("Event"), I, on behalf of myself and on behalf of my heirs, assignees, personal representatives and next of kin and intending to be legally bound, consent to the use of any photos, slides, film or sketches by SCPD taken during the Event for publicity, advertising, promotion or any other purpose in connection with SCPD's work, and further agree to release, indemnify and hold harmless SCPD and its officers, directors, officials, agents and employees, from any and all liability, for loss, harm, damage, injury, cost or expense whatsoever including without limitation, property damage, personal injury (including emotional distress), and/or death which may occur in connection with preparation for, or participation in, the Event, or participation in any Event- related activity, and for any claims or causes of action whatsoever, including, but not limited to, those based on publicity rights, defamation or invasion of privacy, to the fullest extent permitted by law. I agree that any claims or disputes arising from my participation in the Event shall be governed by the laws of the Commonwealth of Pennsylvania, without regard to its conflict of laws provisions, and the Court of Common Pleas of Lancaster County, Pennsylvania shall have exclusive jurisdiction and venue.

I HAVE READ THE FOREGOING WAIVER AND RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I understand that all information typed, read and/or heard pertaining to clients of the Schreiber Center for Pediatric Development is to be kept in strict confidence and not to be transmitted or discussed outside of the Schreiber Center.

I have read Policy 502-Notice of Privacy Practices and Policy 127-HIPAA Confidentiality and Security of Protected Health Information Compliance and have had an opportunity to have my questions answered regarding the Center's Confidentiality and Security of Protected Health Information policy. Confidential information, whether written, verbal, film, or electronic media, may be used or disclosed in a manner, which complies with these policies. I understand that I must comply with these policies and that failure to do so in any way will subject me to disciplinary action, up to and including termination of employment or opportunity to volunteer my services at the Center.

I acknowledge that while volunteering for the Schreiber Center for Pediatric Development, I will act responsibly in the course of my duties solely in the best interests of the institution, in terms of non-disclosure of any HIPPA-protected or proprietary information. In addition, with regard to any inside information as to business activities of the institution or any of its members, I shall refrain from utilizing or sharing in any for such information for the benefit of myself, my immediate family, or any entity in which I may have a material, financial or other beneficial interest. This would include Schreiber's donor database information.

I authorize the Schreiber Center for Pediatric Development (Schreiber), its sponsors and community partners, to use my likeness for media, promotional, or advertising purposes as outlined below.

 I consent to being interviewed, photographed, filmed, audio/video taped, and/or having my voice or image recorded by other electronic or non-electronic means by Schreiber, its employees, or such agents as it may engage for this purpose. I also authorize Schreiber to permit other individuals and entities, including but not limited to representatives of commercial or non-commercial newspaper, magazine, radio, or television related organizations to photograph/film, video/audio tape and otherwise record my child on Schreiber’s premises. I further understand that during any of the previously listed actions, my child’s health information may be disclosed, and unless otherwise noted, my child may be identified by name.

I further consent to the publication and distribution of any of the things outlined above for Schreiber’s own publications or any other broadcast, print, or electronic media. I understand that any elements gathered by Schreiber or outside media may be edited or reused and I waive any right to inspect or approve my depictions in these works.

I understand this authorization is voluntary and I will receive no compensation for any of the uses described above.

I understand that Schreiber or any of its affiliated providers cannot make me sign this authorization as a condition of my child’s treatment, and my refusal to authorize or disclose any of my child’s personal health information will in no way affect my eligibility to receive care at Schreiber.

I understand this authorization will expire ten years from the date on which I signed it. I understand that I may cancel this authorization at any time by contacting the Development Coordinator at 717-393-0425 ext. 106, and that any revocation will not apply to any

materials, in any format, that have already been created, published, or distributed, but will apply to publication or distribution of any future images based on this authorization.

I understand that once such materials are in the possession of the media or members of the general public, Schreiber does not retain control over their editing or use.

RELEASE AND WAIVER

I hereby release Schreiber and each of its trustees, officers, employees and agents, from any and all claims, liability and damages, which might arise from the use of my name, interviews, photographs, films, video/audio tapes, or other recordings and images.

I understand that I am entitled to a signed copy of this authorization.