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Waiver
Who is this registration for?
Please provide a name and email address for a parent or guardian, they will need to sign off for you.
Parent/guardian first name:
Parent/guardian email:
VOLUNTEER WAIVER AND RELEASE OF LIABILITY:
I hereby fully and forever waive, release and relinquish any and all claims, demands and actions whatsoever that I may have against Mission House and WE CARE Clinic, its officers, agents, volunteers and employees, with respect to bodily injury, personal injury, illness, death, or property damage that may arise out of my volunteer activities on Mission House property.
VOLUNTEER STATEMENT OF CONFIDENTIALITY:
As a condition of volunteering with persons seeking assistance from Mission House and Mission House Clinic, I agree to keep confidential any information shared with me. I understand that no information concerning clients and/or patients shall be released to other agencies or persons without signed, written consent of those involved.
I have read these agreements and fully understand their content and agree to them of my own free will, as indicated by my initials and my signature. I further certify that I am 18 years of age or the Parent/Legal Guardian of a minor participant.
VOLUNTEER CODE OF CONDUCT:
1. Sign in and out on the volunteer log each time you volunteer.
2. Be punctual. Notify the Volunteer & Administrative Coordinator and/or the staff member to whom you are assigned if you will be late or cannot fulfill a volunteer commitment. (If I fail to notify Mission House Clinic if I am late or absent I will no longer be able to volunteer) – call 904-241-6767 or email mbloomquist@missiononhousejax.org.
3. Do not bring children or visitors with you to your volunteer assignment.
4. Communicate courteously with all staff members, persons receiving services through our programs (client/patients) and other volunteers. Discrimination in any form will not be tolerated.
5. Maintain confidentiality and abide by HIPPA regulations. Do not share information with anyone about clients/patients without their express written consent, and then, only as required to provide services.
6. Do not disclose personal information about yourself to clients/patients.
7. Do not transport, give money to or purchase items for clients/patients. If you become aware of a need, refer the client/patient to a staff member.
8. Illegal drugs and alcohol are prohibited within our facilities or on our grounds. Smoke in designated areas only.
9. Direct all media inquiries and solicitation requests to the Executive Director.
FOOD HEALTH & SAFETY STANDARDS FOR VOLUNTEER COOKS:
As a volunteer who will be participating in food preparation, service or handling at or for Mission House’s outreach operations (including mobile food service outreach), I understand and agree to the following food safety standards — in alignment with the Florida Department of Health’s regulations (Chapter 64E-11, Florida Administrative Code) and the Duval County Food Hygiene Program under the Florida Department of Health.
1. Personal hygiene & health:
o I will wash my hands thoroughly with hot water and soap for at least 20 seconds before beginning food preparation, after any interruption (such as phone use, break, using the restroom), and after handling raw food, garbage, cleaning cloths or chemicals.
o I will wear clean outer clothing, and restrain hair (hairnet, cap, or other hair restraint) so that hair does not contact food or food-contact surfaces.
o I will not prepare or handle food if I am ill with a communicable disease, have vomiting, diarrhea, a sore throat with fever, or open/infected wounds on my hands/arms, or otherwise known to be a carrier of a disease transmissible through food.
o I agree to follow any additional staff instructions regarding health or hygiene in food-service settings.
2. Food storage, preparation, cooking and service:
o I will only handle foods and food equipment that have been stored properly and are from approved sources.
o I will ensure that potentially hazardous foods (those requiring refrigeration and with time/temperature control for safety) are kept at safe temperatures: at or below 41 °F (5 °C) for refrigerated storage, or at or above 140 °F (60 °C) for hot holding, except during necessary periods of preparation and service.
o I will ensure that food is cooked to minimum safe internal temperatures (for example, poultry to 165 °F for 15 seconds; ground meats to 155 °F for 15 seconds; other raw animal products to at least 145 °F for 15 seconds) in accordance with 64E-11.004.
o If food is prepared and then cooled for later service, I will ensure rapid cooling (e.g., portioned into shallow pans, placed in ice water baths, stirred, or otherwise cooled) so that it reaches 41 °F or below within the required time frame.
o I will avoid cross-contamination: raw animal products (meat, poultry, fish) will be stored below ready-to-eat foods or otherwise physically separated; utensils, cutting boards, surfaces used for raw food preparation will be cleaned and sanitized between uses.
o I will use utensils, tongs or dispensing tools rather than bare hand contact when handling ready-to-eat foods. I will ensure that single-service items (plates, wrappers, utensils) are used when appropriate.
o I will label and date refrigerated, ready-to-eat, potentially hazardous foods stored more than 24 hours, and discard such foods after 7 calendar days (or as required) to prevent foodborne illness.
o I will ensure food transport, service and display protects food from contamination (covers, shields, proper sneeze-guards, protection from dust, pests, overhead leakage).
3. Cleaning, sanitizing & equipment:
o I will ensure that food-contact surfaces, utensils, equipment, and cutting boards are cleaned, rinsed and sanitized before each use, and that the facility is maintained in a sanitary condition at all times.
o I will ensure that sanitizing solutions (chlorine, iodine or other approved agents) are used at correct concentrations (e.g., minimum 50 ppm chlorine at 75 °F or above) and contact times as required.
o I will ensure that refrigerators, freezers, and hot holding equipment are equipped with appropriate thermometers (accurate to ±3 °F) so temperature readings can be monitored.
4. Training & supervision:
o I understand that the facility’s designated certified food manager or designated trained supervisor must oversee operations whenever three or more food workers/volunteers are engaged in storage, preparation or service.
o I commit to attending any required volunteer food-safety orientation provided by Mission House and following all staff instructions and posted protocols.
5. Reporting and compliance:
o I agree to immediately notify the Mission House Food Service Supervisor if I notice unsafe food-handling, unsanitary conditions, pests, illness symptoms among volunteers handling food, malfunctioning equipment, or any situation that could compromise food safety.
o I acknowledge that failure to comply with these food-health and safety standards may result in my removal from volunteer food service duties or termination of my volunteer privileges.
6. Acknowledgment of risk:
o I understand that despite all reasonable precautions, there is a risk of food-borne illness. I accept that volunteering in food preparation and service includes this risk, and I release Mission House and WE CARE Clinic from liability in connection with any food-borne illness resulting from my volunteer activities, except in cases of gross negligence.
By signing below, I certify that I have read, understood and agree to comply with these Food Health & Safety Standards in addition to the general Volunteer Waiver, Confidentiality Statement and Code of Conduct above.
VOLUNTEER WAIVER AND RELEASE OF LIABILITY:
I hereby fully and forever waive, release and relinquish any and all claims, demands and actions whatsoever that I may have against Mission House and WE CARE Clinic, its officers, agents, volunteers and employees, with respect to bodily injury, personal injury, illness, death, or property damage that may arise out of my volunteer activities on Mission House property.
VOLUNTEER STATEMENT OF CONFIDENTIALITY:
As a condition of volunteering with persons seeking assistance from Mission House and Mission House Clinic, I agree to keep confidential any information shared with me. I understand that no information concerning clients and/or patients shall be released to other agencies or persons without signed, written consent of those involved.
I have read these agreements and fully understand their content and agree to them of my own free will, as indicated by my initials and my signature. I further certify that I am 18 years of age or the Parent/Legal Guardian of a minor participant.
VOLUNTEER CODE OF CONDUCT:
1. Sign in and out on the volunteer log each time you volunteer.
2. Be punctual. Notify the Volunteer & Administrative Coordinator and/or the staff member to whom you are assigned if you will be late or cannot fulfill a volunteer commitment. (If I fail to notify Mission House Clinic if I am late or absent I will no longer be able to volunteer) – call 904-241-6767 or email mbloomquist@missiononhousejax.org.
3. Do not bring children or visitors with you to your volunteer assignment.
4. Communicate courteously with all staff members, persons receiving services through our programs (client/patients) and other volunteers. Discrimination in any form will not be tolerated.
5. Maintain confidentiality and abide by HIPPA regulations. Do not share information with anyone about clients/patients without their express written consent, and then, only as required to provide services.
6. Do not disclose personal information about yourself to clients/patients.
7. Do not transport, give money to or purchase items for clients/patients. If you become aware of a need, refer the client/patient to a staff member.
8. Illegal drugs and alcohol are prohibited within our facilities or on our grounds. Smoke in designated areas only.
9. Direct all media inquiries and solicitation requests to the Executive Director.
FOOD HEALTH & SAFETY STANDARDS FOR VOLUNTEER COOKS:
As a volunteer who will be participating in food preparation, service or handling at or for Mission House’s outreach operations (including mobile food service outreach), I understand and agree to the following food safety standards — in alignment with the Florida Department of Health’s regulations (Chapter 64E-11, Florida Administrative Code) and the Duval County Food Hygiene Program under the Florida Department of Health.
1. Personal hygiene & health:
o I will wash my hands thoroughly with hot water and soap for at least 20 seconds before beginning food preparation, after any interruption (such as phone use, break, using the restroom), and after handling raw food, garbage, cleaning cloths or chemicals.
o I will wear clean outer clothing, and restrain hair (hairnet, cap, or other hair restraint) so that hair does not contact food or food-contact surfaces.
o I will not prepare or handle food if I am ill with a communicable disease, have vomiting, diarrhea, a sore throat with fever, or open/infected wounds on my hands/arms, or otherwise known to be a carrier of a disease transmissible through food.
o I agree to follow any additional staff instructions regarding health or hygiene in food-service settings.
2. Food storage, preparation, cooking and service:
o I will only handle foods and food equipment that have been stored properly and are from approved sources.
o I will ensure that potentially hazardous foods (those requiring refrigeration and with time/temperature control for safety) are kept at safe temperatures: at or below 41 °F (5 °C) for refrigerated storage, or at or above 140 °F (60 °C) for hot holding, except during necessary periods of preparation and service.
o I will ensure that food is cooked to minimum safe internal temperatures (for example, poultry to 165 °F for 15 seconds; ground meats to 155 °F for 15 seconds; other raw animal products to at least 145 °F for 15 seconds) in accordance with 64E-11.004.
o If food is prepared and then cooled for later service, I will ensure rapid cooling (e.g., portioned into shallow pans, placed in ice water baths, stirred, or otherwise cooled) so that it reaches 41 °F or below within the required time frame.
o I will avoid cross-contamination: raw animal products (meat, poultry, fish) will be stored below ready-to-eat foods or otherwise physically separated; utensils, cutting boards, surfaces used for raw food preparation will be cleaned and sanitized between uses.
o I will use utensils, tongs or dispensing tools rather than bare hand contact when handling ready-to-eat foods. I will ensure that single-service items (plates, wrappers, utensils) are used when appropriate.
o I will label and date refrigerated, ready-to-eat, potentially hazardous foods stored more than 24 hours, and discard such foods after 7 calendar days (or as required) to prevent foodborne illness.
o I will ensure food transport, service and display protects food from contamination (covers, shields, proper sneeze-guards, protection from dust, pests, overhead leakage).
3. Cleaning, sanitizing & equipment:
o I will ensure that food-contact surfaces, utensils, equipment, and cutting boards are cleaned, rinsed and sanitized before each use, and that the facility is maintained in a sanitary condition at all times.
o I will ensure that sanitizing solutions (chlorine, iodine or other approved agents) are used at correct concentrations (e.g., minimum 50 ppm chlorine at 75 °F or above) and contact times as required.
o I will ensure that refrigerators, freezers, and hot holding equipment are equipped with appropriate thermometers (accurate to ±3 °F) so temperature readings can be monitored.
4. Training & supervision:
o I understand that the facility’s designated certified food manager or designated trained supervisor must oversee operations whenever three or more food workers/volunteers are engaged in storage, preparation or service.
o I commit to attending any required volunteer food-safety orientation provided by Mission House and following all staff instructions and posted protocols.
5. Reporting and compliance:
o I agree to immediately notify the Mission House Food Service Supervisor if I notice unsafe food-handling, unsanitary conditions, pests, illness symptoms among volunteers handling food, malfunctioning equipment, or any situation that could compromise food safety.
o I acknowledge that failure to comply with these food-health and safety standards may result in my removal from volunteer food service duties or termination of my volunteer privileges.
6. Acknowledgment of risk:
o I understand that despite all reasonable precautions, there is a risk of food-borne illness. I accept that volunteering in food preparation and service includes this risk, and I release Mission House and WE CARE Clinic from liability in connection with any food-borne illness resulting from my volunteer activities, except in cases of gross negligence.
By signing below, I certify that I have read, understood and agree to comply with these Food Health & Safety Standards in addition to the general Volunteer Waiver, Confidentiality Statement and Code of Conduct above.
Check here to show you accept the Volunteer Waiver, Statement of Confidentiality, and Code of Conduct. I fully understand its contents and agree to it of my own free will, as indicated by my signature. I further certify that I am eighteen (18) years of age or the Parent/Legal Guardian of a minor participant.
VOLUNTEER WAIVER AND RELEASE OF LIABILITY:
I hereby fully and forever waive, release and relinquish any and all claims, demands and actions whatsoever that I may have against Mission House and WE CARE Clinic, it’s officers, agents, volunteers and employees, with respect to bodily injury, personal injury, illness, death, or property damage that may arise out of my volunteer activities on Mission House property.
VOLUNTEER STATEMENT OF CONFIDENTIALITY:
As a condition of volunteering with persons seeking assistance from Mission House and Mission House Clinic, I agree to keep confidential any information shared with me. I understand that no information concerning clients and/or patients shall be released to other agencies or persons without signed, written consent of those involved.
I have read these agreements and fully understand their content and agree to them of my own free will, as indicated by my initials and my signature. I further certify that I am 18 years of age or the Parent/Legal Guardian of a minor participant.
VOLUNTEER CODE OF CONDUCT:
1. Sign in and out on the volunteer log each time you volunteer.
2. Be punctual. Notify the Volunteer & Administrative Coordinator and/or the staff member to whom you are assigned if you will be late or cannot fulfill a volunteer commitment. (If I fail to notify Mission House Clinic if I am late or absent I will no longer be able to volunteer) – call 904-241-6767 or email mbloomquist@missiononhousejax.org.
3. Do not bring children or visitors with you to your volunteer assignment.
4. Communicate courteously with all staff members, persons receiving services through our programs (client/patients) and other volunteers. Discrimination in any form will not be tolerated.
5. Maintain confidentiality and abide by HIPPA regulations. Do not share information with anyone about clients/patients without their express written consent, and then, only as required to provide services.
6. Do not disclose personal information about yourself to clients/patients.
7. Do not transport, give money to or purchase items for clients/patients. If you become aware of a need, refer the client/patient to a staff member.
8. Illegal drugs and alcohol are prohibited within our facilities or on our grounds. Smoke in designated areas only.
9. Direct all media inquiries and solicitation requests to the Executive Director.
Check here to show you accept the Volunteer Waiver, Statement of Confidentiality, and Code of Conduct. I fully understand its contents and agree to it of my own free will, as indicated by my signature. I further certify that I am eighteen (18) years of age or the Parent/Legal Guardian of a minor participant.
