Amarillo Medication Cleanout March 25, 2023

It is necessary for volunteers to read and agree with the following forms:

Medication Cleanout Volunteer Confidentiality Agreement

Photo Release Form

TTUHSC Release of Liability Form

Zero Tolerance Drug Diversion Policy

After reading the forms, please enter your initials to indicate that you understand and agree with the content. You will be asked to enter your initials 4 different times to indicate agreement with 4 different forms. IMPORTANT: You will then be asked to type your FULL name once on the final item to serve as your digital signature.

WAIVER and RELEASE AGREEMENT

TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

Texas Panhandle Poison Center

Medication Cleanout

I, the undersigned, will voluntarily participate in the above described activity (hereinafter "Activity") and I acknowledge that the nature of the participation could expose me to hazards or risks resulting in injury or death. I understand and agree that if I do not comply with all the rules, regulations, training, and instructions for participation, I may be involuntarily withdrawn from participating. IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN THE ACTIVITY, I HEREBY ACCEPT ALL RISKS TO MY HEALTH AND OF POSSIBLE INJURY OR DEATH THAT MAY RESULT FROM PARTICIPATION (INCLUDING, BUT NOT LIMITED TO, INJURY OR DEATH ARISING FROM: PARTICIPATION IN THE ACTIVITY, FAILURE TO FOLLOW RULES, REGULATIONS, TRAINING AND INSTRUCTIONS, AND/OR INDEPENDENT ACTS BY THIRD PARTIES, AND I HEREBY RELEASE TTUHSC AND ITS GOVERNING BOARD, OFFICERS, EMPLOYEES AND REPRESENTATIVES (COLLECTIVELY REFERRED TO AS "TTUHSC") FROM ANY AND ALL LIABILITY TO MYSELF, MY PERSONAL REPRESENTATIVES, ESTATE, HEIRS, NEXT OF KIN AND ASSIGNS FOR ANY AND ALL CLAIMS AND CAUSES OF ACTION FOR LOSS OF OR DAMAGE TO MY PROPERTY AND FOR ANY AND ALL ILLNESS OR INJURY TO MY PERSON, INCLUDING DEATH, AND ALL CAUSES OF ACTION BOTH STATUTORY AND AT COMMON LAW, WHETHER NOW KNOWN OR UNKNOWN, THAT MAY RESULT FROM OR OCCUR DURING MY PARTICIPATION IN THE ACTIVITY, WHETHER CAUSED BY NEGLIGENCE OF TTUHSC OR OTHERWISE. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS TTUHSC FROM LIABILITY FOR ANY INJURY OR DEATH OR DAMAGE TO PROPERTY THAT MAY RESULT IN MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION WHILE PARTICIPATING IN THE ACTIVITY. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE ABOVE DESCRIBED ACTIVITY WHETHER NOW KNOWN OR UNKNOWN, EITHER STATUTORY OR AT COMMON LAW, AND THAT IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF TEXAS, WHICH SHALL BE THE FORUM FOR ANY LAWSUITS FILED UNDER OR INCIDENT TO THIS AGREEMENT OR ACTIVITY. I certify that I am over the age of 18 and have read this Authorization and Release Agreement and voluntarily accept its terms.

Zero Tolerance Drug Diversion Policy

The Medication Cleanout event provides members of our community the opportunity to bring old, leftover, or no longer needed medications for free and safe disposal. Because of the nature of this event, volunteers may have access to numerous medications that range from over-the-counter to strong prescription drugs. It may seem wasteful to dispose of these medications when we may know of someone who could use them or we might even feel that we, ourselves, could use them. Unfortunately, in this situation, this is called drug diversion and in many cases, this is illegal. Every single medication that is collected at this event must be disposed of. Uniformed law enforcement officers are going to be in attendance at the event to collect some of the most dangerous medications and will also be providing security and oversight. In addition, we will have individuals dressed in plain clothes monitoring the area to ensure that drugs are not being ingested or stolen from the event. If you are uncomfortable handling the medications or being in this area, please let the Volunteer Coordinator know so you may be assigned elsewhere. We do not want anyone to take the chance of going to jail or potentially losing their medical license. If diversion activity does occur, we will be reporting it to the authorities immediately. Also, if you see any suspicious activity, please notify the Event Coordinator as soon as possible.

Medication Cleanout Volunteer Confidentiality Agreement

I understand that during my participation in the Medication Cleanout event I may have access to confidential information, including but not limited to: Patient, client or resident Protected Health Information (PHI) such as medical information, demographics, insurance and billing information. Personal information relating to other volunteers, event sponsors, friends, relatives and the general public. I understand that confidential information is not confined to written materials or hard copy, but includes information derived from any source including, but not limited to, computer data on screen or on disk, and oral communications or recordings. I understand that I should access only that confidential information which is required to perform my duties at the Medication Cleanout event, and that accessing information not needed during the event is considered a breach of confidentiality. I understand that confidential information is to be handled in strict confidence and not to be read, discussed, released, utilized or disclosed to any person without proper authorization or legitimate, professional, need to know for the performance of volunteer duties. I understand that no confidential information is to be taken away from the Medication Cleanout event site. I understand that failure to comply with confidentiality requirements can result in corrective action up to and including termination of volunteer duties and in civil and criminal penalties. I understand that is it my obligation to maintain confidentiality continues throughout the Medication Cleanout event and thereafter. Through the affixation of the my signature, the I acknowledge and certify that I have read and understand this Site Safety Plan and Confidentiality Agreement and I am familiar with its provisions.

Please read!

This question requires you to type your  FULL name, NOT your initials.

There is one more step after this virtual signature.

CLICK HERE TO OPEN A NEW WINDOW TO SELECT YOUR SHIFT. YOU MUST THEN SELECT SUBMIT ON THIS PAGE TO COMPLETE YOUR VOLUNTEER REGISTRATION.

Open Doodle Poll in new window to choose shift.