Release of Liability & Confidentiality Agreement
Acknowledgement of Point In Time Count Volunteer Responsibility, ExpressAssumption of Risk, and Express Release of Liability
In consideration for being allowed to participate as a volunteer for the Point-in-Time (“PIT”) Count survey on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the County of Santa Barbara, the United Way of Northern Santa Barbara County, and participating organizations, and all contractors, employees, officers, directors, volunteers and agents (collectively, the “PIT Leadership”) for any and all claims, including claims of PIT Leadership negligence resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in the PIT Count Process, including travel to, from and during the PIT Count.
I am voluntarily participating in the PIT Count Process. I am aware of the risks associated with traveling to/from and participating in PIT Count, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or others’ actions, inaction, or negligence; conditions related to travel; or the condition of the PIT Count Process location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my voluntary participation in the PIT Count Process, including travel to, from and during the PIT Count Process.
I agree to hold the PIT Count Leadership harmless from any and all claims, including attorney’s fees or damage to my personal property that may occur as a result of my voluntary participation in the PIT Count Process, including travel to, from and during the PIT Count Process. If the PIT Count Process Leadership incurs any expenses related to my personal property or travel to, from or during the PIT Count Process, I agree to reimburse the PIT Count Process Leadership. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
In consideration for my acceptance as a volunteer participant in the PIT Count, and the services and amenities to be provided by the PIT Count Process Leadership in connection with the PIT Process, I confirm my understanding that:
• I have read any rules and conditions applicable to the PIT Count Process made available to me and I acknowledge my participation is at the discretion of the PIT Count Process Leadership.
• The PIT Count officially begins and ends at the location(s) designated by the PIT Count Process Leadership. The PIT Count Process does not include carpooling, transportation, or transit to and from the PIT Count Process, and I am personally responsible for all risks associated with this travel.
• If I decide to leave early and not to complete the PIT Count Process as planned, I assume all risks inherent in my decision to leave and waive all liability against the PIT Count Process Leadership arising from that decision. Likewise, if the PIT Count Process Leadership has concluded the PIT Count Process, and I decide not to return to the end location designated by the PIT Count Process Leadership, I assume all risks inherent in my decision to go forward and waive all liability against the PIT Count Leadership arising from that decision.
• This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part of any provision of this Agreement is held to be invalid or legally unenforceable for any reason, the remainder of this Agreement shall not be affected thereby and shall remain valid and fully enforceable.
• To the fullest extent allowed by law, I agree to WAIVE, DISCHARGE CLAIMS, AND RELEASE FROM LIABILITY the PIT Count Process Leadership, its officers, directors, employees, agents, and leaders from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence of the PIT Count Process Leadership, its officers, directors, employees, agents, and leaders, in any way connected with the Registry Process. I further agree to HOLD HARMLESS the PIT Count Process Leadership, its officers, directors, employees, agents, and leaders from any claims, damages, injuries or losses caused by my own negligence while a participant in the PIT Count Process. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns.
• I have read this document in its entirety and I freely and voluntarily assume all risks of such Injuries and Damages and notwithstanding such risks, I agree to participate in the PIT Count Process.
I do hereby consent and agree that the PIT Count Process Leadership, its employees, or agents have the right to take photographs, videotape, or digital recordings of me beginning on Wednesday, January 29, 2020 at 5:30 am. and ending on Friday, January 29, 2020 at 5:00 p.m. and to use these in any and all media, now or hereafter known, and exclusively for the purpose of the PIT Count Process Leadership. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to the PIT Count Process Leadership, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the PIT Count Process Leadership from all liability, (b) promising not to sue the PIT Count Process Leadership, (c) and assuming all risks of voluntarily participating in the PIT Count Process, including travel to, from and during the PIT Count Process.
I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms.
I have read this entire document and I am signing it freely. No other representations concerning the legal effect of this document have been made by me.
As part of your work to volunteer for the Point-in-Time (“PIT”) Count administered by the United Way of Northern Santa Barbara County, and the Santa Maria/Santa Barbara County Continuum of Care (collectively, “PIT Count Leadership”) you may have access to view, update or modify sensitive information about the PIT Count Process and the PIT Count Leadership, its partners, clients and operation. You must treat this information as confidential and not disclose it with anyone unless specifically authorized in writing by the PIT Count Leadership.
The PIT Count Leadership defines Sensitive Information as including but not limited to:
• Client names, nicknames or any other identifying information
• Client address, location or whereabouts
• Client personal finance information including social security numbers, financial data or related information
• Client health information including information on medical conditions, treatment or history
• Information on PIT Count Leadership and PIT Count Process plans and operations
Any information collected, accessed or viewed, whether it be verbal, written, electronic, printed or any other form, as part of the PIT Count Process, is to be treated as confidential and must not be disclosed. All information related to the PIT Count Process is the property of the PIT Count Leadership and should not be disclosed, released, shared or discussed without prior written authorization from an authorized member of the PIT Count Leadership. This includes communication in any form with clients, co-workers, outside agencies or any other party.
In the event you are unsure if information can be shared, DO NOT DISCLOSE INFORMATION, contact your immediate supervisor or the PIT Count Leadership management to obtain approval.
Unauthorized disclosure of PIT Count Leadership and/or PIT Count Process information may result in disciplinary action, legal action and may result in dismissal from the PIT Count Process.
As a volunteer participant in the PIT Count Process I understand that I may have access to Sensitive Information as determined by the PIT Count Leadership. I agree to maintain the security and confidentiality of survey and related information as well as the security of the PIT Count Leadership IT systems. I will not disclose, share, publish, copy or distribute any survey or PIT Count Leadership and/or PIT Count Process information without express written permission of an authorized member of the PIT Count Leadership. I will not disclose or share my username or password to PIT Count systems to anyone for any reason. I will report any questions, issues or suspicious activities immediately to my supervisor or the PIT Count Leadership management.
Name (Signature) of Volunteer (sign by typing you name)
Email of Volunteer
Name (Signature) of Parent or Guardian (if applicable) (sign by typing your name)
Email of Parent or Guardian (if applicable)
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