By signing below, I, the undersigned volunteer, agree to provide services to SKC Clinic as a volunteer. As a condition of volunteering, I agree as follows:

1. I am donating my services (“SKC Clinic Services”) and I am not entitled to any present or future salary, wages, or other benefits for providing SKC Clinic Services.

2. I understand that the City of Seattle provides limited reimbursement for an injury to a volunteer while providing volunteer services for the City and that the coverage is secondary to any other insurance I may have.

3. I understand that the City of Seattle will appear and defend a claim or lawsuit against me if the claim or lawsuit arises from my volunteer activities, as authorized and limited by Seattle Municipal Code 4.64.100 and .110, except as limited below for professional services provided by clinical providers.

4. I understand I may be exposed to blood, bodily fluids and other potentially infectious materials that may contribute to the risk of acquiring HIV, Hepatitis B or other diseases. If I am exposed, or if there is a circumstance where I am the source of an exposure, I will immediately report the incident to SKC Clinic officials. I understand if I am exposed, SKC Clinic will provide initial blood test(s) at no cost to me and I agree to be tested if I am the source of an exposure. It is further understood that I am responsible for the cost of all subsequent tests, treatments and medical care.

5. I knowingly assume the risk of participating as a volunteer for SKC Clinic. In consideration of participating as a volunteer for the SKC Clinic, I, for myself, my spouse, my legal representatives, heirs, and assigns, hereby forever unconditionally waive all claims (in law, equity, or otherwise) against SKC Clinic, The City of Seattle, Seattle Center Foundation, and their respective subsidiaries, affiliates, partners, officers, trustees, officials, employees, and agents, and volunteers, (collectively, "SKC Clinic Parties"), arising out of my participation in the SKC Clinic and my provision of SKC Clinic Services.

6. In compliance with the federal and state privacy laws, I agree to hold in confidence all personal and protected health information I may overhear or come in contact with during and following the performance of SKC Clinic Services. I further agree not to access, or remove from the premises, personal and protected health information or records unless relating to my performance of SKC Clinic Services. It is understood that I shall be responsible for any direct or consequential damages resulting from my violation of this requirement.

7. I also grant SKC Clinic, City of Seattle/Seattle Center, Seattle Center Foundation and their respective agents the right to use, without payment or consideration of any kind, my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing SKC Clinic services and activities in all forms of media in perpetuity.

8. I agree to notify SKC Clinic officials immediately if I am injured or if I become aware of any accident or injury to another volunteer or clinic participant.

9. I understand that SKC Clinic officials maintain the right to revoke my participation at any time with or without cause.

10. Some volunteer positions may require a Washington State Patrol background check to volunteer for SKC Clinic Services. If required, I will either agree to the background check or I may decline to volunteer.

Special Provisions Applicable to Clinical Providers:

If I am a clinical provider, I also agree as follows:

• I represent that I have all active licenses issued by the appropriate licensing authority which are required in order to provide treatment to patients and that I am not currently subject to any disciplinary action or investigation for criminal or professional misconduct in any jurisdiction.

• I shall inform SKC Clinic officials if my license or disciplinary status changes.

• I am responsible for performing the SKC Clinic Services in a professional manner and in accordance with the standard of care and all applicable laws, rules, and regulations, including, without limitation, receiving a Hepatitis B vaccine.

• If I am licensed in a United States jurisdiction other than Washington State, I agree to submit an attestation to the Washington State Department of Health at least ten (10) working days in advance of volunteering in Washington State.

• I am responsible for the standard of care and quality of treatment I provide patients, and I am not subject to the supervision or control of the City of Seattle or the other SKC Clinic Parties (as defined in 5 above). As a result, I agree that while I am donating my services to the SKC Clinic, I will not be considered a volunteer under the direction of the City of Seattle or the SKC Clinic Parties, and I agree that the provisions of Seattle Municipal Code 4.64.100 and .110 do not and shall not apply. I agree to defend, indemnify and hold the SKC Clinic Parties (as defined in 5 above) harmless from all liability, claims, demands, losses, damages, action or judgments of every kind (including reasonable attorney’s fees) which may occur arising out of my treatment of patients and participation in the SKC Clinic.

• I agree to maintain a professional liability policy relative to my performance of SKC Clinic Services in effect throughout the SKC Clinic. I further agree to inform SKC Clinic of the insurance carrier with whom I have the professional liability policy. I grant SKC Clinic, City of Seattle, Seattle Center Foundation and their respective agents the right to submit any claims arising out of my performance of SKC Clinic Services to the appropriate professional liability carrier for further handling pursuant to the terms of my policy.

• Any follow up treatment provided by me to a patient at a different location or after the SKC Clinic dates is outside the scope of SKC Clinic Services.

• My acceptance of this agreement signifies that I give permission to SKC Clinic to verify the status of my license, my insurance, and my background.

Provision applicable to all volunteers: