Friendly Visiting Volunteer Form

The information that you have been asked to provide is for the purpose of arranging a suitable volunteer driver with a qualified senior. Acceptance of this application is not a guarantee that an appropriate match can or will be made. A Senior Services staff member will contact you regarding the status of your application. We make every effort to maintain confidentiality regarding personal information given.

I hereby give my permission for the Illinois State Police to obtain information relating to my criminal history record through Senior Services Associates. The criminal history record, as received from the reporting agencies, may include arrest and conviction data. I understand that this information will be used in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time.


I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify and hold the Senior Services Associates and officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debits and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer.

This Confidentiality Agreement (“Agreement”) is made and entered into by and between Senior Services Associates, including its subsidiaries and operating units (“Senior Services Associates”) and the individual whose name is set forth at the bottom of this Agreement (“Individual”), as of the date set forth below. For and in consideration of Individual’s access to and use of the Confidential Information (defined below), and for other good and valuable consideration, the receipt, sufficiency, and adequacy of which are hereby acknowledged. Individual agrees as follows:

1. Individual acknowledges and agrees that, by virtue of Individual’s association with Senior Services Associates, through employment, consultation, or otherwise. Individual may be granted access to certain Confidential Information of Senior Services Associates and Senior Services Associates clients. For the purposes of this Agreement, “Confidential Information” shall mean; Client Health Information (defined below); any and all information and data relating to Senior Services Associates, clients, financial information including, but not limited to, billing procedures, forecasts, projections, fee schedules and accounting information, and personnel information. “Client Health Information” shall mean individually identifiable health information of a Senior Services Associates client.
2. Individual acknowledges that Senior Services Associates (or, as the case may be applicable Senior Services Associates client), shall retain ownership of all right, title, and interest in and to the Confidential Information, including, but not limited to, any and all worldwide copyright, patent, trademark, trade secret and other intellectual property rights thereto, and no such rights are transferred to individual hereunder or by virtue of individual’s access to the Confidential Information.

3. Individual shall not, directly or indirectly, disclose, copy, distribute, republish or allow access to any Confidential Information except permitted herein.

4. Individual shall limit his/her access to and use of the Confidential Information solely to that access and use as specifically required by individual’s duties for Senior Services Associate, Inc. In the event individual is a Health Care Provider (defined below), Individual acknowledges and agrees that individual’s use of client Confidential Information shall be limited to that use required (a) in order to facilitate treatment of the client, (b) in order to facilitate payment for health care services rendered, and/or (c) for internal quality oversight review; provided, however, that the Health Care Provider shall not be permitted to disclose psychotherapy notes regarding a client unless prior authorization is first obtained from the client. The Individual shall, in accessing the using the Confidential Information, comply with Senior Services Associates security policies related to the use of such Confidential Information and refrain from using or disclosing more than the minimal amount of Confidential Information necessary to accomplish the intended purpose of the use or the disclosure. For the purpose of this Agreement “Health Care Provider” shall mean a provider of medical services as defined in Section 1171 (3) of the Social Security Act, a provider of medical or other health services as defined in Section 1861 (s) of the Social Security Act and any other person who furnishes health care services or supplies.

5. Individual may disclose Confidential Information if so required by law (including court order or subpoena), provided that Senior Services Associates may require individual to request the appropriate court of governmental body to seal the record that shall contain such Confidential Information.

6. Upon learning of (a) any unauthorized disclosure or use of Confidential Information, or (b) any requirement to disclose such Confidential Information by operation of law, regulation or other legal process, Individual agrees to notify Senior Services Associates immediately, and to cooperate fully with Senior Services Associates to protect the confidentiality of such Confidential Information.

7. Upon request of Senior Services Associates, or upon termination of Individual’s involvement with Senior Services Associates, whether through termination of employment, termination of engagement, or otherwise, individual shall return to Senior Services Associates all Confidential Information furnished to Individual without retaining any copy thereof.

8. Individual acknowledges and agrees that any breach of this Agreement will cause immediate and irreparable injury to Senior Services Associates, that monetary damages will in inadequate to compensate for such breach, and that, in the event of such breach, Senior Services Associates shall be entitled to seek injunctive relief, and any and all remedies available at law or inequity.

9. Individual shall maintain such safeguards and engage in such practices as necessary to ensure that the Confidential Information is adequately protected, including, but not limited to, engaging in the following practices, as applicable: a. not making inquiries with respect the Confidential Information for other personnel who do not have proper authority; b. not disclosing any computer passwords or access numbers to others; c. not making any unauthorized transmissions, inquiries, modification, or purging of data in Senior Services Associates information systems; and d. login off from any computer or access terminal prior to leaving any such computer access terminal unattended, unless a password protected screensaver is activated. e. not removing client files and other confidential information, for any reason, from the individual’s Senior Services Associates office. f. asking client, when interviewing in a public area, if they would be more comfortable in a private setting.

10. Individual acknowledges and understands that all access by Individual to Senior Services Associates information systems will be monitored. (E-mails are the property of Senior Services Associates and will be treated as same.)

This consent for disclosure is valid for the life of the photograph, its negative, videotape, brochure, newsletter, annual report, and/or posting on website or social media. Photographs including negative/videotape/films/social media posts may be archived for future use as noted above. The undersigned does hereby release Senior Services Associates and its successors and assigns from any and all claims for damages for libel, slander and invasion of privacy, or any other claims based on the use of said materials.

I understand that I have the right to inspect and copy the information to be disclosed. I understand that I may revoke this consent by written request at any time. I understand that my refusal to consent to disclosure will result in the photograph/videotape/film/social media post not being disclosed. When photographs/videotapes/films/social media posts are used following this authorization, they may be subject to redisclosure by the recipient and may not be protected by this rule.

I understand that my name will not be released with the aforementioned materials without the express consent to be indicated separately below.