Oregon Mission of Mercy Volunteer Service Agreement
By completing this application on behalf of myself, my personal representatives, heirs, assigns and anyone else entitled to claim through me, I do hereby waive any right of recover, and release the Oregon Dental Association, the Oregon Mission of Mercy, their officers, trustees, officials, employees and agents, and other volunteer dental service providers from liability related to, arising from any and all injury to persons and damage to property, and further agree to undertake to indemnify, hold harmless and defend the Oregon Dental Association, the Oregon Mission of Mercy, from and against any and all claims, damages, actions, liability and expenses including attorney's fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of the volunteer's activities and participating in volunteer services at Oregon Mission of Mercy.
I further acknowledge and agree that the Oregon Dental Association and Oregon Mission of Mercy do not assume any responsibility whatsoever for any property of the volunteer, and the volunteer shall not hold the Oregon Dental Association or Oregon Mission of Mercy liable for any loss or damage to same.
In compliance with the HIPAA Privacy Act: I further agree to hold in confidence all personal and protected health information I may overhear or come in contact with during and following Oregon Mission of Mercy.
I also grant the Oregon Dental Association and Oregon Mission of Mercy and their agents the right to use, without payment of consideration of any kind, my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing Oregon Dental Association and Oregon Mission of Mercy services and their activities in all forms of media in perpetuity.
All clinical providers rendering oral health treatment services must have all appropriate and active licenses issued by the appropriate licensing authority to provide treatment to OrMOM patients. All other volunteers must agree to a cursory background check to volunteer for the OrMOM project. Your acceptance of the Oregon Mission of Mercy Volunteer Service Agreement signifies that you give permission to the Oregon Dental Association and the Oregon Mission of Mercy to verify the status of your license and your background.