Volunteer

In the event of an emergency medical aid/treatment is required due to illness or injury while on Agency property as a volunteer, I authorize Glade Run Lutheran Services to secure and retain medical treatment and transportation needs.

I permit Glade Run to photograph and/or video tape me. I understand and acknowledge that this photograph and/or videotape may be used for the purpose of informing, educating, and/or promoting the services of Glade Run. I acknowledge that I read this statement and I understand it. By signing this release and acknowledgement, I am waiving all legal rights I might have against Glade Run.

I am aware that I may come in contact with confidential client and/or employee information in the routine performance of my duties at Glade Run Lutheran Services. I understand that Glade Run Lutheran Services (Glade Run) has a legal and ethical responsibility to safeguard the privacy of all clients and protect the confidentiality of their health information. I am aware that Pennsylvania State Mental Health Laws prohibit me from releasing any client information to any person or agency. (I have been informed that this includes basic information as client’s name, name of client’s family members, medical diagnosis and reason for placement at this facility, etc.). I understand that written consent of the client (or his/her legal representative) is required for release of information and that all requests for release of client information should be forwarded to the Medical Records Manager at Glade Run Lutheran Services. I understand that any unauthorized release of client information is considered a breach of confidentiality and penalties exist for violation of this trust in accordance with Pennsylvania State Law. I understand that unauthorized release of employee information may result in termination of any future business dealings and/or legal action. I agree that I will report promptly any known or suspected violations of Glade Run’s policies and procedures regarding the privacy of health information to Glade Run’s privacy officer, Chris Phillips, or his designee. Professional boundaries must be maintained with clients and Glade Run Lutheran Services’ staff at all times. Please see reverse for examples of professional boundaries.

All volunteers have a responsibility to apply and maintain professional boundaries with current and former clients and their families and are accountable for their own behavior, regardless of whether any harm was intended. The term “client” refers to any individual who has been or is currently being served by any Glade Run Lutheran Services’ program, including students at St. Stephen’s Lutheran Academy. Examples of prohibited practices with current or former clients: 1. Relationships (personal, sexual, romantic) with clients or family members of the client. 2. Giving clients or clients’ family members personal information such as home telephone number, address, e-mail, cell phone number, Facebook, MySpace, or any personal website or social media information. 3. Sending or receiving text messages. 4. Having a client in your personal vehicle. 5. Taking a client to your home. 6. Relationships between clients and your relatives and friends. 7. Taking photos or movies of a client. Volunteers will be responsible for understanding the difference between befriending (a professional relationship made to meet the client’s needs) and becoming a friend (a non-professional relationship which meets the needs of both people). In the event that you know a client who is receiving services through Glade Run Lutheran Services (for example a neighbor), the parameters of this policy apply. The confidentially of the client must be maintained at all times.

EVERY PARTICIPANT IN ADVENTURES PROGRAM ACTIVITIES SHALL CAREFULLY READ THIS NOTICE BEFORE SIGNING. NO PERSON WILL BE ALLOWED TO PARTICIPATE IN THE ACTIVITY PRIOR TO READING AND SIGNING THIS RELEASE AND ACKNOWLEDGEMENT FORM. TO: GLADE RUN LUTHERAN SERVICES AND ITS AFFILIATES (“GLADE RUN”), its directors, officers, agents, employees, and volunteers. I am aware and understand that there are Inherent DANGERS, HAZARDS, and RISKS, (collectively called “RISKS”) associated with Adventures Program Activities. I ACKNOWLEDGE that these inherent RISKS of Equine, Animal and Other Activities mean those DANGEROUS conditions that are an integral part of Adventures Activities. I freely accept and fully assume all the risks and the possibility of personal injury, death, property damage or loss for myself or for my child as a participant. In consideration of Glade Run permitting the Participant to participate in GLADE RUN ACTIVITIES, I on behalf of myself or my child as the Participant in my capacity as guardian and with the intent that this Release and Acknowledgement be binding on myself and/or the Participant for all legal purposes agree to waive any and all claims that I and/or my child may have against Glade Run and to release Glade Run from any and all liability for any loss, damages, injury, or expense that the Participant may suffer as a result of participation in the activity. Before I signed this Release and Acknowledgment, I read it and I state that I understand it. I am aware that by signing this Release and Acknowledgment, I am waiving all legal rights, which I might have against Glade Run and which the Participant has against Glade Run. In the event of my death or the death of the Participant, by signing this Release and Acknowledgment, I am waiving all rights that my Legal Representatives or the Legal Representative of the Participant may have against Glade Run. I, the undersigned, hereby certify that I am at least eighteen (18) years of age and I am fully capable of understanding and appreciating the risks involved with equine activities. Warning: Under Pennsylvania law an equine professional and equine activity sponsor is not liable for any injury to or death of a participant in equine activities resulting from the inherent risks of equine activities.

By signing and dating this form, I acknowledge that I have read and agree to abide by the policies set forth by Glade Run Lutheran Services in regards to volunteer service at Glade Run.