Holiday Baskets Volunteer Signup HomeHoliday Baskets Volunteer Signup NameThis field is for validation purposes and should be left unchanged.Please sign up by Nov. 21! Volunteer Roles: Basket Packing – Help sort items and pack baskets, stack and wrap baskets for distribution. Basket Pickup Drive Thru – Set up drive thru area, greet staff in cars as they arrive, check off client name from list, deliver basket to vehicle, help with clean up. Deliver Baskets – CICOA STAFF ONLY - Deliver baskets to clients' homes at a pre-arranged time, may need to help carry basket inside home. Ride Along – Board Members or volunteers can ride along with CICOA staff as they deliver the baskets to clients' homes. Pre-Event Help - Assist as needed, possibly with writing cards, packing items, organizing, etc. Name(Required) First Last Email(Required) Cell Phone(Required)Text Message Consent I give consent for CICOA volunteer coordinators to communicate with me via text messages. Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which volunteer activities are you interested in?(Required)Check all that apply. See above for descriptions. Basket packing - December 11, 9:00am-12:00pm Basket pickup drive thru - December 12, 7:30am-1:00pm CICOA STAFF ONLY - Deliver baskets to clients' homes - December 12, between 10:00am-5:00pm Ride along with staff while they deliver baskets - December 12, between 10:00am-5:00pm (specific times will be provided) Pre-event help during days leading up to event (if opportunities are available) STAFF ONLY - if interested in delivering baskets for a case manager that is not able to deliver to their clients, are you willing to deliver outside Marion county?(Required) Yes No Maybe Photos and videos may be taken while participating in this CICOA event. All attendees voluntarily and without compensation give CICOA Aging & In-Home Solutions, CICOA Foundation and those acting under its permission, the right and permission to use these photos and videos for promotional purposes. Attendees waive the right to inspect or approve the finished photographs or recordings. If you would prefer not to be photographed, please let us know with a simple "no thank you" and we will respect your wishes!Confidentiality and Non-Disclosure(Required) I agree to the Confidentiality and Non-Disclosure Agreement.An individual’s Private Health Information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As a CICOA representative, you are required to uphold the expectations as outlined within HIPAA guidelines. I understand I may receive sensitive nature of information as a result of my role as a volunteer and I agree to follow CICOA’s policy on the confidential nature of client information.As a volunteer, I will not intentionally access personal health information not required to complete the tasks within my assigned role. I will not share any personal health information discovered within my assigned role. I will protect the confidentiality of an individual’s personal health information by: • “logging out” any computer program, document or portal before leaving computer unattended • Immediately reporting any perceived or possible HIPAA breach to the volunteer coordinator or a member of CICOA leadership. Checking the box above indicates a commitment to upholding CICOA’s Confidentiality in every circumstance. In addition, my agreement further indicates a commitment to upholding their expectations as outlined within HIPAA guidelines.Voluntary Participation and Liability Release(Required) I agree to the Voluntary Participation and Liability Release.I acknowledge that I have willingly agreed to serve as a volunteer for the CICOA Aging & In-Home Solutions Volunteer Program. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and CICOA Aging & In-Home Solutions, and I sign it of my own free will. In consideration of the opportunity afforded me to participate in this Program, I hereby agree that I, my assignees, heirs, guardians, and legal representatives will not make a claim against CICOA Aging & In-Home Solutions, or any of its affiliated organizations, or either of their officers or directors collectively or individually, or the supplier of any materials or equipment that is used in the project, or any of the other volunteer workers, for the injury or death to me arising from my participation in the project. Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of actions resulting from personal injury or death to me sustained in connection with my participation in the project.
