English as a Second Language
I, ______________________________, will offer my time and services as a volunteer to Hogar Hispano. I hereby acknowledge and state that I am not their employee, nor am I eligible for any compensation or benefits provided to an employee. As a volunteer, I recognize and acknowledge that I am not being compensated in any manner for services rendered. I further recognize and acknowledge that I am not provided with any form of workers’ compensation or disability insurance coverage or other similar insurance program. As a participant in this program, I hereby state that I am aware of and accept the risk inherent in the above program activity.
I have been informed that the Diocesan Insurance Program maintains comprehensive general liability insurance, as well as directors and officers insurance, to protect me as a “Covered Person” for my negligent actions covered under these policies, only while acting in the scope of my defined responsibilities, which may result in damage or injury to another person or persons. However, I acknowledge these policies will not protect me for criminal or intentional acts committed by me. I further understand that there may be no insurance coverage for allegation of negligence in claims of sexual abuse activity involving a minor, which would include hiring, retention, and/or supervision of any kind.
Use of Vehicles
I further acknowledge, with regard to any personal vehicle driven by me as a volunteer that in the event of an accident, there is no coverage afforded to me through the Diocesan Master Insurance Program for physical damage sustained to any vehicle involved or liability incurred by me while operating my vehicle.
Reimbursement of Medical Expenses
I recognize and acknowledge there is volunteer accident coverage as well as medical payments coverage available to me in order to compensate me for expenses I incur from deductibles, co-payments, prescription drugs, or medical services not covered through my own health insurance provider(s) for any injury I sustain as a result of performing my services. I agree that any medical coverage(s) I have will be primary and under no circumstance will I seek any contribution from Hogar Hispano, or their insurer, for any medical expenses until all underlying coverage that may or may not apply is exhausted. I acknowledge that the circumstance and levels of coverage may vary and that the Diocese is under no obligation to continue to maintain any such coverage for my medical expenses.
Informed Consent to Medical Treatment
In the event of an injury, I hereby give Hogar Hispano full authority to take whatever action they feel is warranted under the circumstances regarding my health and safety if I am not in a condition to give informed consent including but not limited to the application of emergency medical procedures, the admittance to a hospital, or the care of a medical professional at my expense.
Further, I agree to follow all procedures and safety precautions set forth by the Diocese and Hogar Hispano in addition to ensuring the protection of minors from sexual misconduct and/or child abuse in order to conform with the requirements adopted by the United States Conference of Catholic Bishops and Catholic Diocese of Arlington Policy on the Protection of Children/Young People and Prevention of Sexual Misconduct and/or Child Abuse.
I freely execute this Acknowledgment with full knowledge of its content and complete understanding of my status and rights as a volunteer.
Signature of Participant Date
Signature of Program Coordinator Date
Please print this form, complete it, and mail it to:
Amy White ♦ ESL Program Coordinator ♦ Catholic Charities Hogar Hispano
6201 Leesburg Pike ♦ Falls Church, Virginia 22044 ♦ 703-534-9805x238 ♦ Fax: 703-534-9809
www.ccda.net ♦ firstname.lastname@example.org