Terms and Conditions
TDA Smiles Foundation
Texas Mission of Mercy, Inc.
Volunteer Agreement
I am submitting an application to serve as a volunteer in the health care event (“Event”) described herein. The Event is sponsored by Texas Mission of Mercy, Inc., an affiliate of the TDA Smiles Foundation, a Texas non-profit corporation organized for charitable purposes. The TDA Smiles Foundation is sponsored by the Texas Dental Association. These three entities are referred to herein collectively as “TMOM Affiliates”. By submitting this application:
1. I acknowledge and agree that I have no expectation of, and neither TMOM Affiliates nor any director, officer, employee, agent or representative of any of them, has offered or will pay me compensation of any kind for the services that I have volunteered to provide for or on behalf of TMOM Affiliates. (Compensation does not include any reimbursement of expenses I incur, if such reimbursement is offered.)
2. I acknowledge that I understand:
a. Texas law may provide certain volunteers with immunity from civil liability for their acts or omissions resulting in death, damage or injury committed or omitted while they act in the course and scope of their duties or functions as a volunteer providing services for or on behalf of certain charitable organizations, including TMOM Affiliates.
b. Texas law does not immunize volunteers from liability for death, damage or injury to others that result from their intentional or willfully negligent acts or omissions, or their acts or omissions done with conscious indifference or reckless disregard for the safety of others.
3. If I am volunteering to provide services for or on behalf of TMOM Affiliates, I represent and warrant to TMOM Affiliates that either:
a. (1) I will serve as a volunteer and I will not receive compensation other than reimbursement for actual expenses incurred.
(2) I will not perform any services which require a license from the State of Texas to perform such services.
Or,
b. (1) I qualify as a “volunteer health care provider” under Texas law.
(2) The services that I provide within the scope of the Event will be within the scope of my license or other eligibility to provide health care services under Texas law.
(3) I will assure that before I provide health care services to a patient within the course and scope of the Event, the patient or the person responsible for the patient (if the patient is a minor or otherwise legally incompetent) has signed a written statement acknowledging (1) that I am not providing care that is administered for or in expectation of compensation and (2) the limitations on the recovery of damages from me, in exchange for receiving health care services from me.
4. I acknowledge that in the course of providing services within the scope of the Event I may gain access to information about Event patients that is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended, and the regulations adopted thereunder (45 CFR Subtitle A, Subchapter C (the “HIPAA Rules”)). I agree to comply in full with the requirements of HIPAA and the HIPAA Rules.
5. I authorize use, by TMOM Affiliates and their designees, of photographs, sound recordings, videos and other recordings of my voice or likeness that they or their agents may make in the course of the Event for the purposes of publicizing, documenting and promoting the charitable activities of TMOM Affiliates in any medium now or hereafter in existence or developed. This authorization is perpetual and irrevocable, and effective world-wide, and is granted without fee or royalty of any kind.
6. I understand that the TMOM Affiliates jointly and severally disclaim all responsibility and liability to me for death, damage or injury to me or any third person or to my property or the property of any third person, that would otherwise arise out of the acts or omissions of any of the TMOM Affiliates in the scope of the Event, including but not limited to the negligent or grossly negligent acts or omissions of any of the TMOM Affiliates. Furthermore, I waive all responsibility and liability to me of the TMOM Affiliates, whether joint or several, for death, damage or injury to me or any third person or to my property or the property of any third person, that would otherwise arise out of the acts or omissions of any of the TMOM Affiliates in the scope of the Event, including actions I undertake and actions of other employees or volunteers involved with the Event, including but not limited to the negligent or grossly negligent acts or omissions or by TMOM Affiliates, other volunteers or employees, of any of the TMOM Affiliates.
7. I hereby agree to indemnify and hold harmless the TMOM Affiliates, both jointly and severally, from and against all claims and causes of action, damages, expenses and other liability, including but not limited to legal costs and expenses, reasonable attorney’s fees and other professional fees, of any third person or awarded to any third person, arising out of or related to my acts or omissions in the scope of the Event or my failure to perform my obligations under this Agreement fully.
8. I recognize and agree that included within the hazards of performing health services on patients in the Event is the possibility that I will come in contact with or be accidently injected with a needle which may contain chemicals or substances from other persons. I recognize that this needle stick hazard is one of the hazards of providing health care to patients and agree that the disclaimer, release and indemnity provisions contained herein contain such needle stick liability.
Definition of Health Care Provider
(1) An individual who is licensed to practice medicine under Subtitle B, Title 3, Texas Occupations Code (“TOC”),
(2) A retired physician who is eligible to provide health care services, including a retired physician who is licensed but exempt from paying the required annual registration fee under Section 156.002, TOC,
(3) A physician assistant licensed under Chapter 204, TOC, or a retired physician assistant who is eligible to provide health care services under Texas law,
(4) A registered nurse, including an advanced nurse practitioner, or vocational nurse, licensed under Chapter 301, TOC, or a retired vocational nurse or registered nurse, including a retired advanced nurse practitioner, who is eligible to provide health care services under Texas law,
(5) A pharmacist licensed under Subtitle J, Title 3, TOC, or a retired pharmacist who is eligible to provide health care services under Texas law,
(6) A podiatrist licensed under Chapter 202, TOC, or a retired podiatrist who is eligible to provide health care services under Texas law,
(7) A dentist licensed under Subtitle D, Title 3, TOC, or a retired dentist who is eligible to provide health care services under Texas law,
(8) A dental hygienist licensed under Subtitle D, Title 3, TOC, or a retired dental hygienist who is eligible to provide health care services under Texas law,
(9) An optometrist or therapeutic optometrist licensed under Chapter 351, TOC, or a retired optometrist or therapeutic optometrist who is eligible to provide health care services under Texas law,
(10) A physical therapist or physical therapist assistant licensed under Chapter 453, TOC, or a retired physical therapist or physical therapist assistant who is eligible to provide health care services under Texas law,
(11) An occupational therapist or occupational therapy assistant licensed under Chapter 454, TOC, or a retired occupational therapist or occupational therapy assistant who is eligible to provide health care services under Texas law, or
(12) An audiologist, assistant in audiology, speech-language pathologist, or assistant in speech-language pathology licensed under Chapter 401, TOC, or a retired audiologist, assistant in audiology, speech-language pathologist, or assistant in speech-language pathology who is eligible to provide health care services under Texas law.
