Volunteer Service Agreement
(Subject to C.R.S. 13-21-115.5 the Volunteer Service Act)
I, the Undersigned, on behalf of myself, my personal representatives, heirs, assigns and anyone else entitled to claim through me, hereby (1) Acknowledge and understand that participation in the services provided by Colorado Mission of
Mercy and COMOM as defined below includes possible exposure to and illness resulting from infectious diseases, including but not limited to COVID-19, and that while precautions and personal discipline may reduce this risk, the risk of
serious illness and even death does exist; and (2) Waive any right of recovery, and release Colorado Mission of Mercy, including its directors, officers, trustees, officials, employees and agents, and other volunteer dental service providers, and
any other organization or company or persons acting on their behalf or sponsoring the Colorado Mission of Mercy dental clinic, all of whom are collectively referred to as COMOM herein, from liability related to the Undersigned, in connection
with bodily injury including death, personal injury and/or damage to property arising from or out of the Undersigned’s activities and participation in volunteer services at the above COMOM dental clinic, and further agree and undertake to
indemnify, hold harmless and defend COMOM from and against any and all claims, damages, actions, liability and expenses, including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of the Undersigned’s activities and participation in volunteer services at the above COMOM dental clinic.
The Undersigned further acknowledges and agrees that COMOM does not assume any responsibility whatsoever for any property of the Undersigned during or in connection with the Undersigned’s activities described above related to the COMOM
dental clinic described above, and the Undersigned shall not hold COMOM liable for any loss or damage to same.
In compliance with the HIPAA Privacy Act: I further agree to hold in confidence all personal and protected health information I may obtain or observe during and following the above COMOM dental clinic.
If I am a dental or healthcare service provider, I hereby certify, I am licensed to perform the types of dental or healthcare services and treatments I am asked to perform, and which are being offered through COMOM volunteer services. I have
provided COMOM with the numbers of my current and valid license which allows me to perform such services.
By completing and submitting this form, the undersigned certifies that he or she is at least 18 years of age (or the undersigned is the legal parent/guardian registering a 16 or 17-year-old volunteer) and has read this Volunteer Service
Agreement and agrees to its terms and conditions. Individuals 15 years or younger may not volunteer.
In consideration of being allowed to participate in the COMOM dental clinic described above, by completing and returning this form, I also grant COMOM and its agents the right to use without payment of any kind, my picture, voice and other
reproductions of my physical likeness in connection with advertising or publicizing COMOM services and its activities in all forms of media in perpetuity.