VOLUNTEER APPLICATION

Additional Information (Make NA if not applicable to you)

As a volunteer member of the workforce at Christ Community Health Services, I authorize CCHS to obtain a NPDB query using the information I have provided in this application. I further agree to release from liability CCHS for their acts performed in good faith and without malice in connection with this application. This release shall be cumulative and in addition to any other applicable immunities provided by law for medical care review activities.

Please ask your current employer to provide a statement attesting to your competence if you are a professionals listed: MD, DO, NP, PA, RN, LPN, CMA, DDS, DMD, RDH, RDA, or other such clinical service provider. This can be emailed to Director of Communications, cris.stovall@christchs.org. or, if your employer prefers to print and sign, it can be included with your return.

Please submit a copy of your government issued ID (DL or passport) when returning this application

CONFIDENTIALITY STATEMENT FOR NON-EMPLOYEES (VOLUNTEERS)

I, {name} will not disclose any information about patients or the medical care they receive at Christ Community Health Services, Inc. I understand and agree that I must hold any patient information in confidence. I have an ethical responsibility to protect patients' privacy. Information regarding patients must not be released, disclosed, or discussed either inside or outside the work area. There are Laws, both state and federal, safeguarding patient records and assigning penalties for the release of confidential information without patient authorization. I understand that intentional or voluntary violation of patient confidentiality may result in punitive action, including possible restriction from work area, fines and/or imprisonment. I also agree that any personal/private information concerning CCHS employees to which I may have access will not be released or discussed either inside or outside the center. Furthermore, I will not under any circumstance copy or disclose business information or the work product of the company for a non-authorized use.

I understand that I have a duty to report any breaches of confidentiality or information security, whether inadvertent or intentional, whether by me or someone else, to my immediate Supervisor or to the Privacy and/or Security Officer to help mitigate any problems caused by such breach. I understand that my obligation to maintain the confidentiality of CCHS patients does not end if my relationship with CCHS is terminated.

I understand and agree that in the performance of my duties for CCHS, during off duty hours, and even after termination of my relationship with CCHS, I will not reveal or discuss confidential patient or business information with anyone unless authorized by

I have read the confidentiality agreement.

Participation Agreement

We are privileged to have a community of physicians dedicated to helping us serve our community of need with compassion, quality, and professionalism. We welcome you to the Christ Community Health Services and would like to share some practices and principles that help guide all of us here at the Christ Community Health Services as we work together.

I agree that I render these health care services voluntarily, without compensation or the expectation or promise of compensation. This acknowledgement and agreement have been made before rendering any services.

I agree to report to the appropriate persons any incidents or injuries in which I am involved with during my volunteer service. I understand that my service as a volunteer is covered up to the limits specified by the center's insurance program and I hereby waive any claim against the center except as specified herein.

Icertify that the statements I have made in this application are true and accurate.

Volunteer Agreement

The information provided is correct and accurate to the best of my knowledge. My signature indicates that I approve for my references to be checked. Christ Community Health Services, CCHS, is not obligated to provide a placement nor am I obligated to accept the position offered. Opportunities are provided for volunteers without regard to religion, creed, race, national origin, age

I understand that volunteering services in clinical settings is not without risk or exposure to disease, including, but not limited to, Human Immunodeficiency Virus (AIDS), Hepatitis B, and other communicable infectious diseases. However, with training, which will be provided as part of the orientation program, and strict adherence by the volunteer to that training, exposure to and risk of contracting disease can be reduced. Understanding this, the undersigned expressly assumes the risks of participating in the volunteer program and releases and discharges Christ Community Health Services, CCHS, their affiliates, and their agents and employees, from any and all liabilities or claims arising from or related to the exposure to or contraction of any disease(s), ailment(s), or condition(s) as a result of participation in the volunteer program at Christ Community Health Services, CCHS.

I acknowledge that, in the event that I become ill or am injured as a result of my participation in the volunteer program, I will not be covered by any employment-related insurance coverage such as worker's compensation and liability insurance, although my health benefits obtained from personal sources may provide coverage. Additionally, I agree that if I am injured or become ill as a result of my participation in the volunteer program, all related costs for medical treatment or associated costs are my responsibili- ty and are not the responsibility of Christ Community Health Services, CCHS.

Background Check Release Agreement:

Iunderstand, given the nature of my work, that Mark Lipman Division of Guardsmark, Inc. may conduct a thorough background investigation and that this investigation will include inquiries as to my abilities, character, and reputation. To facilitate this investigation, I do hereby give my consent and authority for any educational institution, past employment, police agencies, motor vehicle departments, references, worker compensation board, or credit reporting agencies to furnish information from their records to Mark Lipman Division or Christ Community Health Services.

VOLUNTEER CODE OF CONDUCT

AS A CHRIST COMMUNITY VOLUNTEER, I AGREE THAT...

1. I understand that the Volunteer Program reserves the right to terminate my volunteer status as a result of (a) failure to comply with the volunteer policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude (d) unsatisfactory work or appearance; or (e) any other circumstances which, in the judgment of the reporting manager, would make my continued service as a volunteer contrary to the best interests of the CCHS Volunteer Program. I shall at all times uphold the mission, values, and standards of Christ Community Health Services.

2. I shall be punctual and reliable, conduct myself with dignity and respect, be courteous and considerate of others, and endeavor to work professionally with others. I shall attempt to resolve any problems related to my volunteer assignments with my supervisor, and if unsuccessful, attempt to resolve any such problems with the Communications Director (cris.stovall@christchs.org), or with

4. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient.

5. My services are donated to the clinics and/or administration without contemplation of compensation or future employment, and given with humanitarian, religious or charitable reasons.

6. I will provide all the necessary records that are required.

8. I shall make my best effort to fulfill my commitment to the CCHS Volunteer Program by completing all assignments that I accept.

9. I understand that Christ Community Health Services assumes no responsibility for any contact, visits, or services provided by me outside of the responsibilities assigned through the CCHS Volunteer Program.

I have read each of the above conditions and I agree to be bound by them.

Consent and Release of Liability

i, {name} hereby authorize Christ Community Health Services, Inc. and its employees, agents, and authorized representatives, to use, disclose, and/or publish my Protected Health Information contained in photographs and/or audiovisual, and audio taken of me and/or my minor child, with or without names, for such purposes as publicity, promotional materials, advertising, training, newsletters, website, and or all Christ Community Health Services' social

I agree and acknowledge that since me and/or my minor child's participation is voluntary, neither I nor my minor child will receive any compensation. I understand I have the right to refuse to sign this release and I can revoke or cancel this release at any time by sending written notice to:

Christ Community Health Services, Inc.

Attention: Communications/Marketing Department

2595 Central Ave

Memphis, TN 38104

If I revoke or cancel this release, I understand that the revocation will not apply to Protected Health Information that has already been used, disclosed, or published in reliance on my authorization. I understand that any Protected Health Information used, disclosed, or published pursuant to this release is subject to redisclosure and may no longer be protected by HIPAA or other state or federal laws.

I understand that, neither my nor my minor child's, treatment, payment, enrollment in a health plan, or eligibility for benefits is not conditioned on my provision of this release.

I agree to release, defend, and hold harmless Christ Community Health Services, Inc. and its employees, agents, or authorized representatives, from any liability, claims or damages by me or any third party in connection with my participation and the use and/or publication of any video/audio/pictures.

I have read and fully understand this consent and release and agree to the use and publication of video/audio/pictures of me and/or my minor child. A copy of this release is available upon request.