Barstool North Volunteer Form

Barstool North Volunteer Form
Thank you for your interest in volunteering with URS. We truly appreciate your assistance. We are looking for enthusiastic volunteers to help with the 24th Annual North Dayton Barstool Open, a 9-hole, 9-bar, indoor miniature golf outing in the North Dayton area at Rip Rap Roadhouse, Little York Tavern, Submarine House - Vandalia, Maggie's, Wings Bar and Grille, Irish Club of Dayton, Corner Club, Spitfire and The Villa Tavern on Saturday, February 25, 2023! Volunteers will be stationed in one of the 9 bars. During the event volunteers will be in charge of keeping track of and directing teams and keeping team scores. Volunteers will either be assigned to a morning shift (10 am – 2 pm) or an afternoon shift (1:30 – 6 pm). All proceeds benefit children and adults with disabilities and special needs.
Street, City, State, Zip
In case of an emergency, who is the best person for us to contact?
I hereby give to United Rehabilitation Services of Greater Dayton (URS), its nominees, agents and assigns, my free and unlimited consent and permission, waiving all claims for any compensation by reason thereof or damages by reason thereof, (1) to take photographs, moving pictures, videotapes of me and record my voice, (2) to use, publish or republish the same in the furtherance of its work with or without identification of me by name, (3) to use my name and/or information referring to me in conjunction therewith if United Rehabilitation Services so desires, and (4) in furtherance of pictures, videotapes, website and recording to and authorize any newspaper, company or other organization to use, publish, or republish the same with or without the identification of me by name and to use my name and/or information referring to me in conjunction therewith if United Rehabilitation Services so desires. This consent agreement is in effect until otherwise notified in writing to the Executive Director of United Rehabilitation Services of Greater Dayton, by the above signed person or, if a minor, the parent or guardian signed above. Notification revoking the consent applies only to future photographs, moving pictures, website, videotapes, and recording and use of voice recording, not to those already in use.
This agreement is intended to emphasize the importance of our Volunteer Program and our commitment to offering you a positive and rewarding volunteer experience.

We, United Rehabilitation Services, agree to accept your services and commit to the following:

1. To provide adequate information, training, and assistance for you to be able to meet the responsibilities of your positions.

2. To ensure supervisory aid to the volunteer, and to provide feedback on their performance.

3. To respect the skills, dignity, and individual needs of the volunteer, and to do our best to adjust to these individual requirements.

4. To be receptive to any comments from the volunteer regarding ways in which we might mutually better accomplish our respective tasks.

5. To treat the volunteer as an equal partner with agency staff, jointly responsible for accomplishment of the agency’s Mission.

I, as a URS volunteer, agree to serve as a volunteer and commit to the following:

1. To perform my volunteer duties to the best of my ability.

2. To adhere to agency rules and procedures, including recordkeeping requirements and confidentiality of agency and client information.

3. To seek permission and guidance from United Rehabilitation Services staff before taking photographs of clients to ensure we are protecting the confidentiality and rights of our clients.

4. To meet time and duty commitment, or to provide adequate notice so that the staff can adjust to the change.

5. To act at all times as a member of the team responsible for accomplishing the Mission of this agency.

I, as a URS volunteer, agree to serve as a volunteer and commit to the following:

In consideration for permission to participate as a volunteer, I hereby release, waive, discharge and covenant not to sue United Rehabilitation Services (including its officers, directors, trustees, employees and volunteers) for any and all claims, liabilities, demands, costs and expenses which I may incur or claim to incur arising out of or related to services provided relative to this volunteer agreement, whether caused by the negligence of URS and its agents, or alleged as such.

I am fully aware of the risks and hazards connected with the work I have agreed to perform, including but not limited to injury resulting from slips, trips and falls, and I hereby elect to voluntarily participate with full knowledge that any such activities may be hazardous to me and/or my property. I voluntarily assume full responsibility for any risks of loss, property damage or bodily injury, including death, that may be sustained by me, whether caused by the negligence of URS and its agents, or alleged as such.
It is the express intent that this Release bind my spouse and other members of family, as well as my heirs, assigns and personal representatives.
• One of the most important aspects of HIPAA relates to the privacy of personal health information. In December 2000, the Department of Health and Human Services (HHS) issued privacy regulations (standards for Privacy of Individually Identifiable Health Information or “the HIPAA Privacy Rule”) providing standards for the protection of personal health information. This regulations purpose is to protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of the information.

• The HIPAA Privacy Rule established national standards for the protection of health information, as applied to health plans, healthcare clearinghouses, and certain healthcare providers. (Note that these are considered covered entities under both the Privacy Rule and Security Rule).

• Personal Health Information (PHI) is defined as information that is created or received by the Agency and relates to the past, present, or future physical or mental health condition of a participant, the provision of health care to a participant or the past, present, or future payment for the provision of health care to a participant, and that identifies the participant or for which there is a reasonable basis to believe the information can be used to identify the participant. PHI includes information of persons living or deceased and includes name, address, employer, relative names, birthdays, email addresses, etc.

• Penalties begin at $100 per violation, up to a maximum of $50,000. Criminal penalties apply for deliberate offences, ranging from $50,000 and one year in prison, up to $1.5 Million and ten years of imprisonment. Communications with or about patients/clients involving patient/client health information should be private and limited to those who need the information for treatment, payment and health care operations. Only those with an authorized need to know will have access to the protected information. Releasing any of this information for other than permissible purposes is a violation of the HIPAA privacy regulation. Prior to releasing any patient/client information you must have a current signed release from parent/guardian/patient