Volunteer Application

I understand that I am not an employee RSVP, the Atlanta Regional Commission as the sponsor, the volunteer station, or the Federal Government and agree to serve without compensation. I further agree that if I use my automobile to drive to and from my volunteer station or during my service, I will keep in effect automobile liability insurance equal to or greater than the minimum required by the state of Georgia.

I understand that, in the course of my volunteer service with the Atlanta Regional Commission, that my photo may be taken during various activities. I give permission to the Atlanta Regional Commission, Area Agency on Aging, and if applicable, to use photographs taken of me in its publications, on its web site, in videos or in press releases.

I further understand that I will receive no compensation for the use of my photograph.

HIPAA (Health Insurance Portability and Accountability Act of 1996) provides for the safeguarding of each individual’s personal health information (PHI). The federal Department of Health and Human Services has issued a “Privacy Rule” detailing when and how the privacy safeguards apply. The Atlanta Regional Commission (ARC), Aging and Independence Services Group, had adopted privacy policies and procedures to comply with the privacy rule as well as address client confidentiality.

I have received information from ARC to help me better understand how to carry out my responsibilities within ARC volunteer programs. I understand that, based on my duties, access to PHI will be limited only to information, which is the minimum necessary to perform my functions as an ARC volunteer.

In addition, I understand that during my volunteering or other work with ARC, I may see or hear other Confidential Information, including agency operational and financial information, that I must maintain as confidential.

Regardless of the capacity, I understand that I must sign and comply with this Agreement in order to continue to volunteer with ARC.

By signing this Agreement, I understand and agree that:

1. I will keep client information confidential, as highlighted in the Confidentiality and HIPAA Guidelines. Regarding other types of important information, I will keep such information confidential and will only disclose such information if it is required for the performance of my role.

2. I will not discuss any information, either client-related or relating to agency operations, in public areas (even if specifics such as a client’s name are not used), unless that public area is an essential place for the performance of my job.

3. I will keep all security codes and passwords used to access the facility, equipment, or computer systems confidential at all times.

4. I will only access or view client information for that which is required to do my job. If I have any question about whether access to certain information is required for me to do my job, I will immediately ask my supervisor.

5. I will not disclose copy, transmit, modify, or destroy client information or another client confidential information without permission from my supervisor.

6. Once my role with ARC has terminated, I will immediately return all property (e.g., keys, documents, ID badges).

7. Even after my role has terminated, I agree to meet my obligations under this Agreement.

I understand that violation of this Agreement may result in disciplinary action, up to and including termination of my relationship with ARC. This may include civil and criminal legal penalties because of the final Privacy Rule issued by the federal government.

I hereby authorize the Atlanta Regional Commission (ARC), Area Agency on Aging to receive any criminal history record Georgia criminal history record information about me which may be in the files of any state or local criminal justice agency in Georgia.