In Case of Emergency Contact
Work Reference or Probation Officer
Please read carefully
- I certify that the information contained in this application is correct to the best of my knowledge and that any material misrepresentation and/or omission is grounds for dismissal of Community Service from Goodwill of Western & Northern Connecticut or rejection of my application for Community Service.
- I authorize my employers and any other persons or organizations to provide accurate information they have about my background and I release all concerned from the liability in connection therewith.
- I understand that while performing community service at Goodwill of Western & Northern Connecticut I will abide by all policies and procedures in place. My failure to abide by all policies and policies will result in the end of my privilege to earn community service at Goodwill.
Goodwill Confidentiality Agreement
I understand that while I am volunteering my time at Goodwill of Western & Northern Connecticut , I may have access to confidential information.
Data includes issues of consumer care, individual cases involving employment practice, individual consumer identification elements, which may include medical and social information, payor source and risk management concerns. This information is private and should be kept confidential
I agree to use access to systems, if provided to me, in a manner consistent with my approved temporary function and for conduct of work related business only
I understand that a Consumer's rights to the confidentiality of health information are protected by Connecticut State statutes, federal laws and regulations.
I certify that I will not share confidential information. I understand that this restriction is in force at all times and in all locations of Goodwill. I understand that if I fail to keep information confidential, I may be subject to disciplinary action, including revocation of my access and/or termination of my temporary employment. I further understand that if I violate a consumer's or employee's right to privacy and confidentiality, I may be subject to civil or criminal legal action.
Goodwill of Western & Northern Connecticut waiver and release of liability
do hereby release and forever discharge Goodwill of Western & Northern Connecticut , their Officers, Directors, Employees and assigns from any and all claims, demands, causes of actions, suits damages, costs and expenses for any and all personal injuries: loss of profit: pain and suffering: property damage, theft, or other loss rising out of occurring in connection with community service efforts on behalf of Goodwill of Western & Northern Connecticut .
I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, INCLUDING THE FACT THAT I AM RELEASING AND WAIVING CERTAIN POTENTIAL RIGHTS HELD BY ME AND VOLUNTARILY AND FREELY TO THE TERMS AND CONDITIONS SET FORTH