I certify that the information provided in this volunteer application is true and correct and has been given voluntarily.  

I understand that this information may be disclosed to any party with legal and proper interest, and I release Renewed Valor, Inc. from any liability whatsoever for supplying such information. 

I understand that I will not be paid for my services as a volunteer.

In the event for emergency medical aid/treatment is required due to illness or injury during the process of receiving services/volunteering, or while on the property of the Renewed Valor, Inc. This authorization includes x-rays, surgery, hospitalization, medication, and any treatment procedure deemed “lifesaving” by the physician.  The provision will only be invoked if the volunteer is not responsive, and the emergency contact is unable to be reached.

Consent is NOT given for emergency medical aid/treatment in the case of illness or injury during the process of receiving services/volunteering or while on the property of Renewed Valor, Inc. In the even emergency aid/treatment is required.

I acknowledge and understand the inherent risks of equine activities and that horsemanship experiences can result in injury and even death. In consideration for being accepted into the Renewed Valor Program and for the benefits I receive from participating/volunteering in the program, I, the below signee hereby consent to assume the risks of my participation in the program sponsored by Renewed Valor, Inc.

Accordingly, I hereby, intending to be legally bound, for myself, my heirs, assigns, executors, and/or administrators, waive and forever release, acquit, discharge and hold harmless, Renewed Valor, Inc.; the owners of the facilities and properties on which Renewed Valor Inc. conducts its therapeutic and equine-related programs and activities, including but not limited to, City of Adams, and the City of Lincoln; the officers, directors, agents, employees, representatives, therapists, counselors, farriers, instructors, and volunteers of Renewed Valor, Inc.; and any other person associated with Renewed Valor, Inc. therapeutic and equine-related programs and activities, and the successors and assigns of each and all the above-mentioned parties, from all manner of claims, demands and damages of every kind and nature whatsoever. I may know or in the future have against these parties due to any loss or personal injury, physical or mental condition, whether known or unknown to myself, and the treatment thereof, as a result of, or in any way connected with Renewed Valor, Inc. therapeutic and equine-related programs and activities, or growing out of acts or omissions or caused by negligence or in any way incidental to Renewed Valor, Inc. therapeutic and equine-related programs and activities. I have asked, or have had the opportunity to ask, and and all questions that I may have relating to the risks involved in therapeutic and equine-related programs and activities. I fully understand and accept these risks.

In consideration for being accepted as a volunteer into the Renewed Valor Inc. therapeutic horseback riding program and for the valuable benefits I receive from participating in the program and promoting the program I hereby authorize Renewed Valor, Inc., its advertising agencies and/or the news media to have photographs, films or other audio-visual materials taken of myself for promotional material, educational activities, exhibitions or for any other use for the benefit of Renewed Valor, Inc. program.  I hereby indemnify and hold Renewed Valor, Inc. harmless against any and all claims of damage arising out of the use of any such photographs or films or me or audio-visual materials containing my image.

THIS AGREEMENT entered into the below signature date and by and between Renewed Valor, Inc. known as the “Therapeutic Facility”, and applicant named below, Known as the “Volunteer”, and known collectively as the “Parties”, set forth the terms and conditions under which information created or received by or on behalf of this facility (known collectively referred to a protected health information, or “PHI”) may be used or disclosed under State law and the Health Insurance Portability and Accountability Act of 1996 and updated through HIPAA Omnibus Rule of 2013 and will also uphold regulation enacted there under (hereafter “HIPAA”).

THEREFORE, in consideration of the premises and the covenants and agreements contained herein, the Parties hereto, intending to be legally bound hereby, covenant and agree as follows:

1. Confidential Information. The Parties acknowledge that safety while volunteering may or will necessitate disclosure of confidential information by this program to the Volunteer and use of Confidential Information by the Volunteer. The tern “Confidential Information” includes, but is not limited to, PHI, any information about the participants or other volunteers, participant records or billing information, any participant lists, and financial information about the program or its participants that is not public, any intellectual property rights of Practice, and proprietary information of Practice and any information that concerns this program contractual relationships, relates to this program’s competitive advantages, or is otherwise designated as confidential by this program.
2. Disclosure. Disclosure and use of Confidential Information includes oral communications as well as display or distribution of tangible physical documentation, in whole or in part, from any source or in any format (e.g., paper, digital, electronic, internet, social networks, magnetic or optical media, film, etc.). The Parties have entered into this Agreement to induce use and disclosure of Confidential Information and are relying on the covenants contained herein making any such use or disclosure. This program, not the Volunteer, is the records owner under state law and the Volunteer has no right or ownership interest in any Confidential Information.
3. Applicable Law. Confidential information will not be used or disclosed by the Volunteer in violation of applicable law, including but not limited to HIPAA Federal and State records owner statute; this Agreement; the Practice’s Notice of Privacy Practices, as amended; or other limitations as put in place by Practice from time to time. The intent of this Agreement is to ensure that the Volunteer will use and access only the minimum amount of Confidential Information necessary to perform the Volunteer’s duties and will not disclose Confidential Information outside this program unless expressly authorized in writing to do so by this program. All confidential Information received (or which may be received in the future) by Volunteer will be held and treated by him or her as confidential and will not be disclosed in any manner whatsoever, in whole or in part, except as authorized by this program and will not be used other than in connection with the employment relationship.
4. Gate and Door Codes and Passwords. The Volunteer understands that he or she may be given a gate and or door code or password by Practice, which may be changed as this program, in its sole discretion, sees fit. The Volunteer will not change the gate and or door code or password without Renewed Valor’s permission. Nor will the Volunteer leave this Confidential Information unattended or give out to individuals without permission first.
5. Returning Confidential Information. Immediately upon request by Renewed Valor, the Volunteer will return all Confidential Information to Renewed Valor and will not retain any copies of any Confidential Information, except as otherwise expressly permitted in writing signed by Renewed Valor. All Confidential Information, including copies thereof, will remain and be the exclusive property of Renewed Valor, unless otherwise required by applicable law. The Volunteer specifically agrees that he or she will not allow anyone working on their behalf or affiliated with the Volunteer in any way, use any or all the Confidential Information for any purpose other than as expressly allowed by this Agreement. The Volunteer understands that violating the terms of this Agreement may, in this program sole discretion, result in disciplinary action including termination of employment and/or legal action to prevent or recover damages for breach. Breach reporting is imperative.
6. Breach. The Parties agree that any breach of any of the covenants or agreements set forth herein by the Volunteer will result in irreparable injury to Renewed Valor for which money damages are inadequate; therefore, in the event of a breach or an anticipatory breach, Practice will be entitled (in addition to any other rights and remedies which it may have at law or in equity, including monetary damages) to have an injunction without bond issued enjoining and restraining the Volunteer and/or any other person involved from breaching this Agreement.
7. Binding Arrangement. This Agreement shall be binding upon and endure to the benefit of all Parties hereto and to each of their successors, assigns, officers, agents, volunteers, shareholders, and directors. This Agreement commences on the date set forth above and the terms of this Agreement shall survive any termination, cancellation, expiration, or other conclusion of this Agreement unless the Parties otherwise expressly agree in writing.
8. Governing Law. The Parties agree that the interpretation, legal effect, and enforcement of this Agreement shall be governed by the laws in the State of Nebraska and by execution hereof, each party agrees to the jurisdiction of the courts of the State. The Parties agree that any suit arising out of or in relation to this Agreement shall be brought in the county where Renewed Valor’s principal place of business is located.
9. Severability. If any provision under this Agreement shall be held invalid or unenforceable for any reason, the remaining provisions and statements shall continue to be valid and enforceable.

IN WITHNESS WHEREOF, and intending to be legally bound, the Parties hereto have executed this Agreement on the date first above below, when signing below and after training on HIPAA Law with full understanding this agreement shall stand.

The Health Insurance Portability Act of 1996 (HIPAA) requires or privacy officer to train volunteers on our health information privacy policies and procedures to the HIPAA Omnibus Standards of 2013 which also includes HI-TECH and Protected Health Information (PHI), Electronic Protected Health Information (ePHI), and Electronic Health Records (EHR). All Volunteers with treatment, payment, or Therapeutic operations responsibilities, which allow access to protected health information, are trained with updates periodically as State and Federal mandates require. HIPAA also requires that we keep this documentation (that the training was completed) for six years after the training.

I, the undersigned, do hereby certify that I have received, read, understood, and agree to abide by Renewed Valor HIPAA Policies and Operating Procedures.

Renewed Valor, Inc. is an alcohol and drug-free workplace. Renewed Valor prohibits the possession, sale, consumption, or being under the influence of alcoholic beverages, marijuana, or any illegal drugs by employees, contract workers, or volunteers while on the premises of Renewed Valor or any satellite location, during working hours, outside the office, while on agency business, or in an agency vehicle. Any employee, contract worker, or volunteer found possessing, selling, consuming, or being under the influence of alcoholic beverages or marijuana while on duty will be subject to discipline, up to and including termination or be precluded from being a volunteer. Prescription drugs or over-the-counter medications, taken as prescribed, are an exception to this policy.

Occasional exceptions to this policy against the consumption of alcoholic beverages may be made at the Executive Director’s or vote by the Board of Directors’ discretion for small quantities of such beverages reasonable under the circumstances, usually wine or beer, which may be available at office parties or Renewed Valor sponsored events on property. At such parties and events, all personnel are expected to exercise good judgment and moderation. In no event may any underage individual consume alcohol at any Renewed Valor sponsored event, and all personnel are expected to comply fully with all laws (including laws prohibiting the operation of motor vehicles while under the influence of alcohol), and to take safety precautions including arranging for a designated sober driver.

Renewed Valor, Inc. expects all employees, contract workers, team members, volunteers, and clients to treat each other and those whom they may encounter while representing Renewed Valor with respect and integrity.  Inclusion is a vital tenant of our organization.  

Anyone who displays behavior that could be detrimental to any of the parties listed above, or endanger them in any way, will be asked to leave the premises immediately.

The code of conduct also applies to our property, horses, and other animals.