Donate Life Ambassador Sign-Up

Page 1

Contact Information

First Name

Last Name

Address Information

Street Address	City
State	Zip Code

Phone(s) and Email

Mobile Phone	Home Phone
Work Phone	Other Phone

Demographic Information

Date of Birth

We often have outreach events to groups of diverse ethnicity (i.e. Festival de la Familia, La Salud, and Pacific Rim Festival). It is helpful to know the ethnic background of our volunteers to involve them in community events in which they may share a similar background.Please feel free to provide us with this information. If you feel uncomfortable, please skip to the following question.

With which ethnicity/ ethnicities do you identify?

Languages Spoken

What other language(s) do you speak?

What is your religion/faith so that we may connect you with religious groups for public speaking opportunities??

Emergency Contact Information

First Name

Last Name

Relation

Phone

Phone Type

Page 2

Your Story

Do you have a connection to donation or transplantation?

Please tell us how your life has been affected by organ donation or transplantation

What are your reasons for volunteering?

Where did you hear about the Donate Life Ambassador Program?

Pre-Transplant Candidate Information

Please tell us about the transplant center(s) you are currently listed with.

Transplant center name

Date you became listed

Please tell us about the transplant(s) you are waiting for.

Please tell us what you are waiting for:

If you selected "Other" beside, please specify:

Pre-Transplant Candidate Family Information

Please tell us about the candidate and your relationship to them.

The candidate is my:	If you selected "Other" beside, please specify:
Candidate's (full) name	Candidate's date of birth

Please tell us about the transplant center(s) the candidate is currently listed with.

Transplant center name

Date they became listed

Please tell us about the transplant(s) the candidate is waiting for.

Please tell us what they are waiting for:

If you selected "Other" beside, please specify:

Donor Family Information

Please tell us about the donor and your relationship to them.

The donor is/was my:	If you selected "Other" beside, please specify:
Donor's (full) name	Donor's date of birth
Hospital where donation occurred	Date of donation

Please tell us about the donation(s) made.

Please tell us what organs were donated	If you selected "Other" beside, please specify:
Please tell us what tissues were donated	If you selected "Other" beside, please specify:

Living Donor Information

Please tell us about the recipient and your relationship to them.

The recipient is/was my:	If you selected "Other" beside, please specify:
Recipient's (full) name	Recipient's date of birth
Hospital where donation occurred	Date of donation

Please tell us about the donation(s) made.

Please tell us what organs you donated

If you selected "Other" beside, please specify:

Transplant Recipient Information

Please tell us about your transplant history.

Transplant center name

Organ(s) received

Date of Transplant

Please tell us about the relationship to the donor or their family

Have you been in contact with your donor or their family?	Are you a recipient from a living donor?
The donor is/was my:	If you selected "Other" beside, please specify:

Transplant Recipient Family Information

Please tell us about the recipient and your relationship to them.

The recipient is/was my:	If you selected "Other" beside, please specify:
Recipient's (full) name	Recipient's date of birth

Please tell us about the recipient's transplant history.

Transplant center name

Organ(s) received

Date of Transplant

Page 3

Your Interests and Connections

Which of the following volunteer activities would you be interested in?

With which of the following audiences are you comfortable speaking?

To which of the following classroom audiences are you comfortable presenting?

Do you belong to any civic groups or know any community leaders (celebrities, company owners, television/radio management, etc.) who would want information about donation?

Please provide the names of the people and/or organizations:

Page 4

Donate Life Ambassador/Volunteer Confidentiality Agreement

I am a Donate Life Ambassador/volunteer at DCI Donor Services (DCIDS, Sierra Donor Services, Tennessee Donor Services, New Mexico Donor Services). As a volunteer of my time and abilities for DCIDS, I understand that I will be viewed by the community as a representative for organ, eye and tissue donation as well as DCIDS. I agree to conduct myself in a professional manner which will promote organ donation and the image of DCIDS.

As a Donate Life Ambassador/volunteer, I acknowledge and agree to the following:

Please initial beneath each of the following statements to confirm your agreement/understanding.

1. I understand that DCIDS and all its locations are Medicare certified organ procurement organizations and is required by law to maintain the confidentiality of all information related to the donation of anatomical gifts. The deceased who made the gift and the donor family has a reasonable expectation of and a legal right to privacy of the information concerning an anatomical gift. I further understand that both DCIDS and I have a legal and ethical responsibility to safeguard the privacy of all donors and donor families.

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2. In the course of my volunteering at/for DCIDS or any location, I may come into contact with confidential anatomical gift donation information and I agree that during the course of my volunteer work with DCIDS and at all times thereafter: (a) I will maintain the confidentiality of information related to anatomical gift donation and the deceased person making the donation; (b) I will not view, access or otherwise use or disclose any of DCIDS’s information except as is necessary to perform my volunteer work; and (c) I will not discuss DCID’s information where others may overhear the conversation (for example, in hallways, on elevators, at lunch, on public transportation, at social events).

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3. I understand that my violation of this Agreement will result in DCIDS and locations removing me as a volunteer.

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4. I understand that nothing in this Agreement shall be construed to be an employment contract between DCIDS and myself. Additionally, I understand that nothing in this Agreement is to be construed as conferring any employment rights on me or changing my status from that of a volunteer for DCIDS.

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5. I agree to indemnify and hold DCIDS harmless from any and all claims, damages, liabilities, judgments, including, but not limited to, reimbursement for any penalties incurred by DCIDS pursuant to violations of law related to confidentiality violations, including reasonable attorney fees, which DCIDS may incur as a result of the performance or breach of my responsibilities, obligations, warranties and representations under this Agreement during or after the term of this Agreement.

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6. I agree to indemnify and hold DCIDS locations harmless for any injury that I might sustain while volunteering with DCIDS. I further agree to indemnify and hold DCI harmless from any claims, damages, liabilities and judgments of any nature arising out of my volunteer work with DCIDS locations.

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7. I understand that my phone number and address will be released to DCIDS and DCIDS location staff and Donate Life Ambassadors or fellow volunteers for events and communication ONLY. No volunteer is permitted to use the Donate Life Ambassador director for any other use.

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8. I agree that the provisions of this agreement shall be governed in all respects by, and be construed in accordance with, the laws of the State of California.

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Signature

By entering your name below, you agree to adhere to the statements/guidelines expressed above.

Signer's Name

Date of Signature

Contact Information