Volunteer Application

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.

CICOA requires criminal background checks for all volunteers. I understand that CICOA requires criminal history and/or driving record background checks for the purpose of evaluating me for a volunteer position. I understand that a background check is a consumer report which is covered under the Fair Credit Reporting Act. The consumer report may include the following areas: verification of social security number, criminal history records, and motor vehicle records to include traffic citations and registration. I hereby authorize CICOA to obtain a Consumer Report, to verify information that I have voluntarily supplied. This authorization and consent shall be valid in original, on-line, fax or copy form. I certify that the information contained on this form is true, correct and complete to the best of my knowledge. I also understand that any misrepresentation, falsification or omission of facts herein may be grounds for disqualification or separation.

If a volunteer decision which adversely affects me is made based upon information obtained through a consumer report, I understand that I have the right to request a free copy of the report. If I dispute the information, I have the right to conclusively demonstrate the inaccuracy of the information.

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.