Alaska Mission of Mercy Volunteer Service Agreement.
As a volunteer for the Alaska Mission of Mercy, I hereby agree to respect each patient’s rights to self-determination and confidentiality, to refrain from harming the patient, to promote the patient’s welfare, to treat people fairly, and to communicate truthfully.
I acknowledge and agree that the Alaska Dental Society (ADS), the Alaska Mission of Mercy (AKMOM) and the Alaska Dental Society Charitable Activities Fund (ADSCAF), hereinafter referred to as the “ENTITIES”, do not assume any responsibility whatsoever for any of my personal property and I shall not hold the ENTITIES liable for any loss or damage to the same.
In compliance with the HIPAA Privacy Act: I agree to hold in confidence all personal and protected health information that I may overhear or come in contact with prior to, during and following the Alaska Mission of Mercy project.
I also grant the ENTITIES and their agents the right to use, without payment or consideration of any kind, photographic, voice and other reproductions of my physical likeness, in connection with publicizing and/or advertising the ENTITIES’ activities and services in all forms of media, in perpetuity.
I understand that clinical providers rendering oral healthcare treatment services must have all the necessary, appropriate and active professional licenses issued by the appropriate licensing authorities and the requisite liability insurance to provide treatment to Alaska Mission of Mercy patients and that all volunteers must agree to a background check to participate in the AKMOM project. My acceptance of this AKMOM Volunteer Service Agreement gives explicit permission to the ENTITIES to verify my background and the status of my professional licenses.
To view the printable version, click the link here: Volunteer Service Agreement