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Volunteer with CT Coalition to End Homelessness

| Fairfield County Youth Count

January 23rd - 29th, 2019
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Disclaimer

Youth Count 2018


Volunteer Release and Confidentiality Form

First and Last Name:
Address:
City, State, Zip:

Phone: E-mail: Agency Affiliation (if any):
Release:

By signing below, I understand that I represent to the FAIRFIELD

Continuum of Care that I am over the age of 18. I hereby agree to hold harmless and release the FAIRFIELD Continuum of Care;

iits member organizations, their boards/trustees, employees, volunteers, count organizers; and other participants in the Connecticut Youth Count from any liability for any accident, injury or death or any theft or loss of property arising from the participation as a volunteer in the Youth Count, regardless of whether incurred as a result of negligence or other. I voluntarily assume these and any other risks in participating in the count and waive all claims and causes of action that may arise out of participation in the count.


I understand that as a volunteer for the Youth Count it will be necessary for me to handle and process confidential information. I acknowledge that I will keep all information confidential while a volunteer and that it is my responsibility to keep this information confidential even after I end my volunteer duties for the Youth Count. I understand that I am not to disclose any identifying confidential information and/or records or to engage in casual or informal conversation identifying any individual involved in the count.

I have read and fully comprehend the information pertained in this form and agree to the terms of this release. By signing below I acknowledge that it is my responsibility to comply with all relevant laws, policies, and regulations concerning access, use, maintenance and disclosure of information made available to me as a volunteer in the Youth Count.

Signature Date