Volunteer - Paw Paw 2024-09-08

AMEN Free Clinic | Paw Paw SDA Church

Paw Paw, MI | September 8, 2024

Seeking Michigan Licensed medical professionals or volunteers seeking to serve in non-medical roles.

What area do you wish to volunteer in?
Medical Department is Full but other areas are open.
Which days will you volunteer?

Personal Information

For example MD, DDS, RN
Address
Address
City
State/Province
Zip/Postal
Country

Emergency Contact

Are you planning to serve as Licensed Provider for this clinic?

Volunteer Area

Dental Area Licensed
Dental Area Other
Medical Area Licensed
Medical Area Other
Vision Area Licensed
Vision Area Other
General Volunteer
Student/Instructor

Specialties

Medical Specialties
Dental Specialties

License

Maximum file size: 268.44MB

Languages Spoken Fluently
I am interested in helping to lead a department

Release and waiver of liability

Please read carefully! This is a legal document that affects your legal rights!

The Volunteer desires to work as a volunteer for AMEN and engage in the activities related to being a volunteer for a free medical and dental clinic (the “Activities”). The Volunteer understands that the Activities may include physical labor, exposure to bio-hazardous materials such as blood and saliva, exposure to dental cleaning chemicals, exposure to sharp instruments and tools, and/or other circumstances that may result in personal injuries.

The Volunteer hereby freely, voluntarily, and without duress executes this Release under the following terms:

1. Release and Waiver
Volunteer does hereby release and forever discharge and hold harmless AMEN and its successors and assigns from any and all liability, claims, demands and whatever kind or nature, either in law or in equity, that arise or may hereafter arise from Volunteer’s Activities with AMEN. Volunteer under stands that this release discharges amen from any liability or claim that the volunteer ma y have against AMEN with respect to any bodily injury, personal injury, illness, death, or property damage that may result from volunteer’s activities with AMEN, whether caused by the negligence of AMEN or its officers, directors, employees, or agents or otherwise. Volunteer also understands that AMEN does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

2. Medical Treatment
Volunteer does hereby release and forever discharge AMEN from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Volunteer’s Activities with AMEN.

3. Assumption of the Risk
The Volunteer understands that the Activities may involve work that may be hazardous to the Volunteer, including, but not limited to, cleaning, lifting, exposure to chemicals, exposure to bio-hazardous waste, and risks from transportation to and from the clinic. Volunteer hereby expressly and specifically assumes the risk of injury or harm in the Activities, and releases AMEN from all liability for injury, illness, death, or property damage resulting from the Activities.

4. Insurance
The Volunteer understands that, except as otherwise agreed to by AMEN in writing, AMEN does not carry or maintain health, medical, or disability insurance coverage for any Volunteer. Each Volunteer is expected and encouraged to obtain his or her own medical or health insurance coverage.

5. Photographic Release
Volunteer does hereby grant and convey unto AMEN all right, title, and interest in any and all photographic images and video or audio recordings made by AMEN during the Volunteer’s Activities with AMEN, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

6. Other
Volunteer expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Tennessee, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Tennessee. Volunteer also agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

I, the volunteer, have executed the release as of the day and year written below. I understand that this constitutes a legal signature confirming that I acknowledge and agree to the above terms of acceptance.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.
Are you under 18?
I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.