Confidentiality Agreement

Samaritan Village, Inc. Confidentiality Agreement & Liability Release Form

This online form is a formal agreement between Samaritan Village, Inc. and the signer, as a means to protect the location of Samaritan Village, Inc.’s residential property location, identification of residents of Samaritan Village, Inc., and all Samaritan Village, Inc.’s data.

This agreement is meant to make expectations clear for all volunteers, staff, board members and visitors who may gain access to highly sensitive information of Samaritan Village, Inc.

Confidentiality Form

Full Name(Required)

First Name Last Name

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Role(Required)

Describe your role at Samaritan Village

Group Outreach Name

If applicable, please designate the group / church you are affiliated with for volunteer outreach.

Residential Location & Program Information

I agree to keep confidential the location of Samaritan Village’s Safe House. I will not share its location with anyone, at anytime and for any reason.(Required)

I agree

I disagree

I will not bring anyone to the Safe House at anytime, for any reason.(Required)

I agree

I disagree

I will avoid accidental disclosure of the location through texts, emails or verbal conversations, and I will deactivate any locations finding apps. If at any time the location is disclosed, I will alert the Program Manager immediately.(Required)

I agree

I disagree

I will not take any photographs using a camera or cell phone while at the safe house.(Required)

I agree

I disagree

I agree to keep all residents' names and any other identifying information confidential by refraining from discussing residents in public, through emails or text messages with anyone other than the Staff of Samaritan Village.(Required)

I agree

I disagree

I will not discuss the resident’s behaviors nor resident information with anyone besides Samaritan Village Staff.(Required)

I agree

I disagree

I will not use any information of any kind, obtained through my interactions with residents or staff, written or verbal for my own personal use, including social media posts or sharing with others.(Required)

I agree

I disagree

Data Protection

I understand that I may come into contact with confidential information during my time at Samaritan Village, Inc. I agree to never remove any confidential material of any kind from the premises unless authorized as apart of my duties or obligations to the organization, or with permission.(Required)

I agree

I disagree

CONFIDENTIALITY & DATA PROTECTION: I acknowledge that any sensitive, proprietary, private or otherwise undisclosed information regarding Samaritan Village, Inc. and its residents are to be kept private. This includes, but is not limited to research, spreadsheets, projects, correspondence, reports, and presentations and may only be used in the course of providing services to Samaritan Village, Inc.(Required)

I agree

I disagree

NO DISCLOSURE WITHOUT AUTHORIZATION: All sensitive, proprietary, private or otherwise undisclosed information regarding Samaritan Village, Inc. and its residents, including but not limited to finances, donors, volunteers, supporters, stakeholders, strategies, and plans shall be kept in confidence and used only for the sole purpose of aiding the objectives of the ministry and will not be disclosed or used for any other purpose.(Required)

I agree

I disagree

NO ACCESS WITHOUT AUTHORIZATION: Access to private information sharing systems used by Samaritan Village, shall be used only for the sole purpose of aiding the objectives of Samaritan Village, Inc. and will not be used for any other purpose.(Required)

I agree

I disagree

Liability Release

I hereby assume all responsibility for any and all risk of property damage or bodily injury that I may sustain while participating in any voluntary relief effort, disaster exercise or other activity of any nature, including the use of equipment and facilities of Samaritan Village, Inc.(Required)

I agree

I disagree

Further, I, for myself and my heir, executors, administrators and assigns, hereby release, waive and discharge Samaritan Village, Inc. and its officers, directors, employees, agents and volunteers of and from any and all claims which I or my heirs, administrators and assigns ever may have against any of the above for, on account of, by reason of or arising in connection with such volunteer relief efforts or my participation therein, and hereby waive all such claims, demands and causes of action.(Required)

I agree

I disagree

Further, I expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.(Required)

I agree

I disagree

I currently have no known mental or physical condition that would impair my capability for full participation as intended or expected of me. Further, I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as my own, free act.(Required)

I agree

I disagree

Performance Authorization, Release, and Waiver of Liability

In consideration of the permission granted to me by Samaritan Village, Inc. to participate and/or have my video, audio, photographic and other copyrighted materials used (hereinafter referred to, collectively, as “My Participation”) in the ___________, I hereby release Samaritan Village, Inc., the State of Florida, the Board of Directors, and their officers, employees and agents from all actions, damages, or claims which I or my assigns may have against them which may be incurred as a result of My Participation in the above-described Program.(Required)

I agree

I disagree

Further, I agree to indemnify and hold harmless Samaritan Village, Inc., the Board of Directors, and their officers, employees and agents from any liability, loss or expenses arising from any claim or litigation that My Participation in the Program including my statements or actions, or material furnished by me violated or infringed the rights of third parties.(Required)

I agree

I disagree

I authorize the use of my name, voice, photograph, likeness, performance and/or biography by Samaritan Village, Inc., the Board of Directors, and their officers, employees and agents in connection with any use of a product arising out of My Participation in the above-described Program. I authorize Samaritan Village, Inc., to obtain and hold copyrights in such Program and products, and to edit my performance and materials in its sole discretion.(Required)

I agree

I disagree

I understand that Samaritan Village, Inc. has no obligation to air the Program, and that I will receive no monetary compensation for the rights granted herein. I understand and affirm that this Authorization and Release shall be considered consent to such use by Samaritan Village, Inc. under the provisions of Florida Statutes.(Required)

I agree

I disagree

I, the undersigned, am at least 18 years of age or I am the parent or guardian of a participant who is less than 18 years of age. I have read this Performance Authorization, Release, and Waiver of Liability and understand all its terms. I execute it voluntarily and with full knowledge of its significance.(Required)

I agree

I disagree

I AGREE(Required)

By typing your full name into the form below, you agree to abide by all of the aforementioned policies and agreements and it is equal to my full authorization.

Date(Required)

MM slash DD slash YYYY

Parental Consent Form

If you are 18 or over, you do NOT need a parental consent form

Do you require a Parental Consent Form?(Required)

Yes, I am under 18

No, I am 18 or older

I, the parent or guardian of _______, give my voluntary consent to his/her participation in Samaritan Village, Inc.‘s Outreach Service Project(Required)

I agree

I disagree

I hereby release Samaritan Village, Inc. the State of Florida, the Board of Directors and their officers, employees and agents from any and all liability resulting from events beyond control.(Required)

I agree

I disagree

In the event of an accident, injury, or illness, the above stated and its agents do not assume any responsibility or obligation to provide financial assistance or other assistance, including but not limited to, medical, health, or disability insurance, in the event of an accident, injury, illness, death or property damage. In the event of an accident, injury, or illness, the above stated and its agents will make every effort to contact parents/guardians immediately if necessary.(Required)

I agree

I disagree

Furthermore, I release Samaritan Village, Inc., the State of Florida, the Board of Directors, and their officers, employees and agents and volunteers for any loss, personal injury, accident, misfortune, or damage to the above name or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above name.(Required)

I agree

I disagree

I AGREE(Required)

By typing your full name into the form below, you agree to abide by all of the aforementioned policies and agreements and it is equal to my full authorization.

Date(Required)

MM slash DD slash YYYY

If you have any questions, please contact us.

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