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Saturday, May 21, 2016

9:30 a.m. – 3:00 p.m.

Our Lady of Perpetual Help Catholic Church
1600 Morris Rd., SE
Washington, DC 20020

Volunteer Registration Form

First Name *

Last Name *

Phone *

Email Address *

T-Shirt Size *

Non-Clinical Volunteer Roles

Clinical Volunteer Roles

Comments/Additional Information

Authorization for Photo and Media Release

1. I hereby authorize Ascension and its hospitals, affiliates, subsidiaries and contractors to photograph, interview, use and publish my photographic or video image, or the photographic or video image of my minor child(ren) or my property.

2. I understand that the photographic or video image, or media interview may be produced and released in any media form, including, but not limited to, internet, newspaper, television, radio and/or marketing materials, in whole or in part, with such alterations and changes as Ascension desires, and that the images or interview may appear separately or with my name or the name(s) of my minor child(ren) included in this Authorization.

3. I understand that the purpose of the use or release of the images and media interview will be for education, marketing or public relations purposes.

4. The use or release of the images or media interview may be made to the public through education, marketing and public relations efforts for commercial or noncommercial publications, exhibits, and/or on the intranet and internet.

5. I agree that all pictures, reproductions, negatives, tapes of any kind relating to the images, and materials relating to interviews are, and shall remain, the property of Ascension and its agents to whom permission has been granted. If I should receive any print, negative or other copy thereof, I shall not authorize its use by anyone else.

6. I agree that no advertisement, photograph or other material need be submitted to me for approval, and Ascension shall be without liability to me for any distortion or illusionary effect resulting from the publication of my video, picture, portrait, likeness, or comments.

7. I understand that my signing this Authorization does not obligate Ascension to make use of any photographic or video images or media interviews.

8. I understand that this Authorization can be revoked by me at any time by submitting a written request to Ascension Communications, 101 S. Hanley, Suite 1100, St. Louis, MO 63105.

9. I understand that my revocation will not apply in those instances in which Ascension has acted upon this Authorization prior to the revocation being received by Ascension.

10. I understand that the information released pursuant to this Authorization may be subject to re-disclosure and no longer protected by state and federal privacy laws.

11. I hereby release and discharge Ascension from any and all claims, actions, and demands arising out of or in connection with the use of any photographic or video images or media interviews without limitation.

12. I understand that Ascension cannot require me to sign this Authorization as a condition of providing treatment to me or my minor children or obtaining payment for treatment.

13. I understand that my signing this Authorization is voluntary, not a requirement of my employment at Ascension, and that I will not face any repercussions on my employment status if I so choose not to sign this Authorization.

14. If no specific date is indicated, this Authorization will expire in ten (10) years.

I have read and had the opportunity to have my questions answered and understand the above terms and conditions and hereby authorize Ascension and its hospitals, affiliates, subsidiaries and contractors to photograph, interview, videotape and publish named image as described in this release.

I have read and agree to the terms above. *

I agree

Confidentiality Agreement

I understand that in the performance of my duties as a volunteer for Providence and its affiliates (the Medical Center), I may have access to and be involved in the observation or gathering or processing of confidential patient and/or business information.

Confidential patient information includes all information, whether spoken, written, or electronic, pertaining to a patient, the patient's condition, and events surrounding the patient's hospitalization and payment for services provided.

Confidential business information includes all information whether spoken, written or electronic pertaining to Medical Center business plans, payroll/employee information and other information related to Medical Center operations.

I understand as a condition of my performance of duties for the Medical Center that I am required to maintain the confidentiality of this information at all times, including after my duties at the Medical Center have terminated.

I also understand and agree that I will only access information which is needed to perform my duties or when required by Providence's policy, federal or state law, or applicable regulation. I also understand that no patient identifiable information shall be included in any report that may be generated for any educational activities I may be participating in or in any other third party publication unless consented to by the patient or expressly authorized by the Medical Center.

I understand that Providence's computer systems are proprietary and are to be used by authorized individuals only. Authorized use of the network and electronic communications shall be consistent with Administrative and Human Resources policies and guidelines. Such systems are to be used for business and research purposes only. Personal activities utilizing the Providence's computer system are prohibited.

I understand the Medical Center reserves the right to monitor its computer systems and electronic communications or other use of such systems at any time, without notice, to ensure the systems are being used for appropriate business or research purposes. Anyone using these systems consents to such monitoring. If such monitoring reveals possible illegal activity or inappropriate use, it may result in loss of access privileges and/or discipline up to and including termination of employment or other relationship with the Medical Center or its affiliates.

I understand that inappropriate use of electronic communications includes, but is not limited to offensive, defamatory, obscene or inappropriate communication. Transmission of harassing messages or participation in unethical/illegal activities is strictly prohibited.

I understand electronic communication accounts and passwords are to be used by the designated authorized individual only and are not to be shared. I agree to not share my password with anyone.

I understand that a violation of these confidentiality considerations may result in disciplinary action, up to and including termination of my duties at Medical Center or its affiliates or termination of my employment. I further understand that I could be subject to legal action for breach of confidentiality.I have read and I understand the Medical Center confidentiality policy, and I will abide by its provisions.

I have read and agree to the terms above. *

I agree

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