This information is optional, but is used in grant reporting and county statistics.

You can indicate here which services you are willing to perform.

To protect our members KFNV uses The Senior Connection (https://www.seniorconnectionmc.org/) to
conduct routine reference checks on every volunteer.

Please provide two personal references (non-relative) with address and phone number.

By providing these references, you grant The Senior Connection permission to check with these references.

This section to be completed only by those volunteering to be drivers. Driver agrees to maintain and keep their vehicle in proper working order and condition.

I hereby certify that all information I have supplied in this volunteer application is complete and accurate. I understand that by submitting this application, I authorize inquiries to be made concerning my suitability as a volunteer and that this application is not a guarantee that I will be accepted as a volunteer with KFNV and Senior Rides. I also give permission for a criminal background, three year MVA driving record check and other checks, if applicable. Further, I acknowledge that participation in any KFNV and/or Senior Rides program as a volunteer does not constitute employment with the KFNV and/or Senior Rides and that I am not covered by any type of Worker’s Compensation program while performing duties associated with volunteering. I understand that KFNV and/or Senior Rides does not unlawfully discriminate in employment or volunteer appointments and no question on this application is used for the purpose of limiting or excusing any applicant from consideration on a basis prohibited by applicable local, state or federal law. I agree to comply with and be bound by the organization’s safety and health rules and regulations, rules of conduct, and any other policy and/or rule or
procedure set by the organization.

In consideration of this opportunity to volunteer, I agree to the following terms and conditions, intending to be legally bound by them: I will abide by the mission, rules, regulations, policies and programs of King Farm Neighbors Village and the Senior Rides Program while I am a volunteer.

I fully understand the nature of the volunteer activities that I will be performing on behalf of the King Farm Neighbors Village and the Senior Rides and hereby confirm that I am qualified, in good health, and in proper physical condition to participate in such activities. I further agree and promise that if at any time I believe conditions associated with such activities are unsafe, I will immediately discontinue further participation in such activities and will advise the King Farm Neighbors Village and the Senior Rides Program of the perceived unsafe conditions. I assume all risks in connection with my volunteer work for the King Farm Neighbors Village and the Senior Rides Program. I acknowledge and agree that the King Farm Neighbors Village and the Senior Rides Program, its directors and officers, its volunteers or any of its representatives, are not liable to me for any injuries, damages, liabilities, losses, judgments, costs or expenses which I might suffer or sustain in connection to the performance of my volunteer activities for the King Farm Neighbors Village and the Senior Rides Program.

On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless the King Farm Neighbors Village and the Senior Rides Program and its directors, officers, employees, volunteers and agents from any claims, causes of action and demands of any nature, whether known or unknown, arising out of or in
connection with my volunteer work for the King Farm Neighbors Village and the Senior Rides Program.

I will indemnify, defend and hold the King Farm Neighbors Village and the Senior Rides Program harmless from and against any claims, lawsuits, injuries, damages, losses, costs or expenses sustained by any animal or any person in connection with my participation in the King Farm Neighbors Village and the Senior Rides Program activities, including but not limited to my intentional misconduct or grossly negligent performance of volunteer activities for the King Farm Neighbors Village and the Senior Rides Program, or my breach of the King Farm Neighbors Village and the Senior Rides Program rules, regulations, policies and programs.

If I suspend volunteer activities, or upon request, I will promptly return all the King Farm Neighbors Village and the Senior Rides Program supplies, equipment, records, moneys and other items in good, clean, serviceable condition. I acknowledge and agree that the King Farm Neighbors Village and the Senior Rides Program shall have the right to terminate my involvement with the King Farm Neighbors Village and the Senior Rides Program at any time with or without prior notice. Any modification to this Agreement must be in writing and signed by both parties. This Agreement is binding upon the King Farm Neighbors Village and the Senior Rides Program, King Farm Neighbors Village and the Senior Rides Program representatives, me and my respective heirs, successors, assigns, executors and personal representatives.

Photography Release: I grant and convey to the King Farm Neighbors Village and the Senior Rides Program all right, title and interest in any and all photographic images in which I appear including video or audio recordings, made by the King Farm Neighbors Village and the Senior Rides Program or others on the King Farm Neighbors Village and the Senior Rides Program’s behalf during my volunteering or work for the King Farm Neighbors Village and the Senior Rides
Program, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

I expressly agree that this Waiver is intended to be as broad and inclusive as permitted by the laws of the State of Maryland, and that this Waiver shall be governed by and interpreted in accordance with the laws of the State of Maryland. I agree that in the event that any clause or provision of this Waiver 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 agree to all the terms stated above. I will abide by them and not dispute or take issue with them in any way.

All information concerning members, former members, our staff, volunteers, and financial data, and business records of the KFNV and Senior Rides is confidential. “Confidential” means that you are free to talk about the KFNV and Senior Rides and about your program and your position, but you are not permitted to disclose members’ names or talk about them in ways
that will make their identity known. No information may be released without appropriate authorization. This is a basic component of member care and business ethics. The board of directors, staff and our members rely on paid and volunteer staff to conform to this rule of confidentiality.

KING FARM NEIGHBORS VILLAGE and Senior Rides expect you to respect the privacy of members and to maintain their personal and financial information as confidential. All records dealing with specific members must be treated as confidential. General information, policy statements or statistical material that is not identified with any individual or family is not classified as confidential. Staff members are responsible for maintaining the confidentiality of information relating to other staff members and volunteers, in addition to members.

Failure to maintain confidentiality may result in termination of your participation, or other corrective action. This policy is intended to protect you as well as the KFNV and Senior Rides because in extreme cases, violations of this policy also may result in personal liability.

Rationale
Confidentiality is the preservation of privileged information. By necessity personal and private information is disclosed in a professional working relationship. Part of what you learn is necessary to provide services to the member; other information is shared within the development of a helping, trusting relationship. Therefore, most information gained about individual members through an assignment is confidential in terms of the law, and disclosure could make you legally liable. Disclosure could also damage your relationship with the member and make it difficult to help the person.

Before you begin your assignment as a staff member/volunteer, you should be aware of the laws and penalties for breaching confidentiality. Although the organization is liable for your acts within the scope of your duty, giving information to an unauthorized person could result in the organization's refusal to support you in the event of legal action. Violation of the state statutes regarding confidentiality of records is punishable upon conviction by fines or by imprisonment or by both.

Certification
I have read the KFNV and Senior Rides policy on confidentiality and the Statement of Confidentiality presented above. I agree to abide by the requirements of the policy and inform the volunteer coordinator immediately if I believe any violation (unintentional or otherwise) of the policy has occurred. I understand that violation of this policy will lead to disciplinary action, up to and including termination of my service with the KFNV and Senior Rides.