Vivalon Volunteers Make a Difference
One Meal, Ride, Connection at a Time

I UNDERSTAND THAT IF I AM INJURED IN THE COURSE OF THE PROJECT, I AM COVERED BY Vivalon’s AD&D-TRAVEL ACCIDENT PROGRAM. Coverage is afforded provided that

1.) I am acting at Vivalon’s direction and within the scope of my duties as a volunteer for Vivalon;

2.) The accident takes place during the policy period;

3.) The expenses that are incurred are reported within one year of the date of the accident. Payments will be made regardless of fault (not to exceed the applicable limit of insurance) and include reasonable expenses for:
– First aid administered at the time of an accident;
– Necessary medical, surgical, X-ray and dental services, including prosthetic devices; and
– Necessary ambulance, hospital and professional nursing and funeral services.

I acknowledge that during the course of my volunteer role with Vivalon I will have access to certain information not generally known to the public.

I understand that this information is Confidential Information and agree that it is not to be shared at any time. I understand the need to safeguard, in any format including, but not limited to, database records, email, any other electronic format, hard copy, voicemail or conversation.

I understand that participant records are protected under confidentiality regulations and cannot be disclosed without written consent of the participant, as stated in HIPAA.

1. All Confidential Information provided to or generated by me, both hard-copy and electronic, is highly confidential. It is not to be discussed with anyone not conducting Vivalon business.

2. I agree to protect all Confidential Information when in use, storing it properly when not in use, and discussing it only with those who have a legitimate business need to know.

3. I agree to treat Confidential Information with care during my volunteer role with Vivalon.

4. I will not give data to persons not authorized to access it. I understand that Vivalon expressly forbids the disclosure of private data or the distribution of such data in any medium, except as required by my volunteer duties and responsibilities.

5. I understand that if I am found compromising information that I may be released in my volunteer role with the organization.

If I am applying to volunteer, which will involve driving my own vehicle or a company vehicle on behalf of Vivalon, I hereby authorize Vivalon’s insurance company and/or Heffernan Insurance Brokers to be in possession of my driver’s license number, obtain the necessary motor vehicle records and authorize them to send a copy of my Motor Vehicle Record to Vivalon.