We're In The Business of Changing Lives

Release of Liability & Confidentiality Agreement

"*" indicates required fields

I, the undersigned, hereby release and agree to hold harmless Community Intervention & Educational Services, its members, affiliates, and employees or loaned executives of any and all liability that could possibly be incurred as a result of my negligence, intentional or unintentional, during the commission of my responsibilities as a volunteer for Community Intervention & Educational Services or the “THE COOL PROGRAM”.

I further release and hold harmless Community Intervention & Educational Services or the “THE COOL PROGRAM”, its members, affiliates, and employees or loaned executives of all liability with regard to any physical or emotional harm that I may sustain during the time I volunteer at the Safe Haven, or as a result of my participation in the project as a volunteer, or in any other activity sanctioned by Community Intervention & Educational Services, “COOL PROGRAM”.

Additionally, I agree to the following:*

Please check each item as you read and agree.

My role is as a volunteer, and, as such, I will receive no financial reimbursement for services rendered.

I have completed the required training and have been made aware of the assigned duties.

I will bring to the attention of CIES / COOL PROGRAM staff any information or questions that arise of a legal nature.

I recognize that any and all information shared with me as part of my duties as a volunteer is confidential and shall not be divulged to unauthorized individuals, agencies, or organizations.

I will not copy, transcribe, record, or memorize confidential information in any manner, nor disclose or use such information for any purpose other than for the limited purpose of providing the assigned services at the Safe Haven.

THIS AGREEMENT shall be governed by and construed in accordance with the laws of the State of North Carolina.

I have had the opportunity to read and understand the release and acknowledge that by signing the document, I am waiving certain legal rights in the event of injury.

BY SIGNING BELOW, I accept and agree to the terms contained above.

Signature Date*

Signature*

This field is for validation purposes and should be left unchanged.