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Draft Forms For Susan to Review

CONFIDENTIALITY STATEMENT

In consideration of the volunteering for The Academy, it is hereby agreed as follows:

Confidential Information

The Academy will at all times maintain transparency with Members, sponsors and the general public. Information concerning sponsors and/or Membership development efforts and plans shall not be used to benefit the efforts of any other organization.

Any request by a sponsor to remain anonymous or to limit information provided to the public shall be honored, except to the extent that The Academy is legally required to disclose the identity of sponsors. All information about sponsors will be kept strictly confidential by The Academy and its representatives unless the sponsor grants permission to release such information.

During my period of volunteer work, The Academy may disclose or cause to be disclosed to me, confidential information including, but not limited to, Membership, client, or personnel matters, such as information regarding cases and salaries, medical treatment or diagnosis, terminations, layoffs or promotions, and disciplinary measures regarding individual directors, officers, employees, contract employees, other volunteers, financial information regarding contractual arrangements, pricing, letters of agreement or understanding, intellectual property developed by The Academy, identifiable confidential matters, or information regarding prospective business of The Academy. I recognize such information to be the property of The Academy and I agree to hold such information in trust and solely for The Academy benefit and not to disclose such information to those inside or outside The Academy either during or after volunteering, without the written consent of a Director of The Academy.

Upon leaving The Academy, I agree not to take with me, without first obtaining the written consent of a director of The Academy, any document or tangible evidence of confidential information or data belonging to, or under the control of, The Academy, whether on disk, record or hard copy, whether an original or a reproduction.

Volunteer Name(Required)
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VOLUNTEER LIABILITY WAIVER AND AGREEMENT

Oklahoma Academy of Physician Assistants, Inc. (The “Academy”) is a non-profit corporation. The Academy regularly engages volunteers in its activities. In consideration for my ability to participate in Academy activities, by signing below, I, the Volunteer (or the Volunteer’s legal guardian, on the Volunteer’s behalf), agree that:

Policies and Safety Rules:

For my safety and that of others, I will comply with The Academy’s volunteer policies and safety rules and its other directions for all volunteer activities

Awareness and Assumption of Risk:

I understand that my volunteer activities may have inherent risks that may arise from The Academy’s activities themselves, operations, my own actions or inactions, or the actions or inactions of directors, officers, employees, contract employees, other volunteers, and others present at Academy events. These risks may include, but are not limited to, working in situations with many people and therefore exposed to illnesses, working in emotional or volatile environments, working at event venues, lifting objects, and performing repetitive tasks. I assume full responsibility for any and all risks of bodily injury, death, or property damage caused by or arising directly or indirectly from my presence or participation at Academy events or participation in Academy activities, regardless of the cause.

Waiver and Release of Claims:

I waive and release any and all claims against The Academy its directors, officers, employees, contract employees, and volunteers (associates), for any liability, loss, damages, claims, expenses and attorney’s fees (or attorneys’ fees) resulting from death, or injury to my person or property, caused by or arising directly or indirectly from my presence at Academy events, or participation in activities on behalf of The Academy, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the Released Parties on the basis of these waived and released claims. I understand that The Academy would only permit me to volunteer with my agreement to these waivers and releases

Medical Care Consent and Waiver:

I authorize The Academy to provide to me with medical personnel of its choice to provide medical assistance, transportation, and emergency medical services. This consent does not impose a duty upon The Academy to provide such medical assistance, transportation, or emergency medical services. Additionally, I waive and release any claims against the associates arising out of any treatment, or medical service, including the lack or timing of such, made in connection with my volunteer activities with The Academy.

Indemnification:

I will defend, indemnify, and hold all associates harmless from and against any and all loss, damages, claims, expenses, and attorney’s fees (or attorneys’ fees) that may be suffered by any associate resulting directly or indirectly from my volunteer activities for The Academy, except and only to the extent the liability is caused by the gross negligence or willful misconduct of the relevant associate.

Publicity:

I consent to the unrestricted use of my image, voice, name, and/or story in any format including video, print, or electronic (materials) that any associate or others may create in connection with my participation in activities at or for The Academy. The Academy may make the materials available at its discretion to third parties, including photos, streamed, or other videos, on The Academy’s website and internal displays, in The Academy’s publications, or through any other media, including social networking websites. I waive any right to inspect or approve the finished product and acknowledge that I am not entitled to any compensation for creation or use of the finished product.

Confidentiality:

As a volunteer, I may have access to sensitive or confidential information. This information includes, but is not limited to, identity, address, contact information, credit card numbers, and financial information of The Academy clients, volunteers, sponsors, and associates. At all times during and after my participation, I agree to hold in confidence and not disclose or use any such confidential information except as required in my Academy volunteer activities or as expressly authorized in writing by The Academy’s Executive Director

Publicity and Photo Release:

I consent to the unrestricted use of my image, voice, name, and/or story in any format including video, print, or electronic (materials) that any associate or others may create in connection with my participation in activities at or for The Academy. The Academy may make the materials available at its discretion to third parties, including photos, streamed, or other videos, on The Academy website and internal displays, in The Academy. publications, or through any other media, including social networking websites and apps. I waive any right to inspect or approve the finished product and acknowledge that I am not entitled to any compensation for the creation or use of the finished product.

Volunteer Not an Employee

I understand that: 1) I am not an employee of The Academy. 2) I will not be paid for my participation. 3) I am not covered by or eligible for any insurance, health care, worker’s compensation, or other benefits.

I may choose at any time not to participate in an activity, or to stop my participation entirely, with The Academy.

Volunteer Name(Required)
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POLICY CONFIRMATION STATEMENT

I have read and been informed about the content, requirements, and expectations of the policies for Oklahoma Academy of Physician Assistants, Inc. (The “Academy”). I have received a copy of the policies and agree to abide by the policy guidelines as a condition of volunteering as a Board Director or Officer for The Academy, including the following:

• Whistleblower Policy

• Conflict of Interest Policy

• Code of Ethics

• Social Media Policy

• Media Policy

• Insurance Policy

• Indemnification Policy

• Sexual and other Harassment Policy

• Record Retention Policy

I understand that if I have questions at any time regarding any policies for The Academy I will consult with the Executive Director or President.

Please read all policies carefully to ensure that you understand them before signing this document.

Board Member Name(Required)
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BOARD SERVICE AGREEMENT

As a board member of Oklahoma Academy of Physician Assistants, Inc. (hereinafter referred to as The “Academy”). I am fully committed and dedicated to the purpose of The Academy and have pledged to carry out such purpose. I understand that my duties and responsibilities include the following:

1. I understand my legal responsibilities are to make good faith decisions (a duty of care); to be true to the purpose of the organization (a duty of obedience); and, to act in the best interest of The Academy (a duty of loyalty).

2. I am responsible for the oversight and implementation of the Bylaws and policies of The Academy.

3. I will take an active part in reviewing, approving, and monitoring the budget.

4. I will make maintain my Membership in good standing with The Academy.

5. I will attend board meetings and be available for phone consultations.

6. I will read all consent agenda documentation prior to meetings.

7. I will maintain the confidentially of information received through my service at The Academy and will sign the Confidentiality Statement per the Governance Manual.

8. I will adhere to the policies of The Academy and I acknowledge that I have received, read, will follow such policies, and will execute the Policy Confirmation Statement per the Governance Manual. I understand the policies and their necessity to the tax-exempt status of The Academy.

9. I will take an active part to ensure The Academy is not being utilized to promote, advertise, market, sell or distribute intellectual property, goods, or services which would lead to any form of private benefit to any member of the board or other individual.

10. I will volunteer to be a member of at least one committee.

11. If I am unable to meet my obligations as a board member, I will offer my resignation.

In signing this document, I understand that no rigid standard of measurement and achievement are being formed. I understand every board member is making a statement to act in the best of his or her abilities.

Board Member Name(Required)
MM slash DD slash YYYY

ANNUAL CONFLICT OF INTEREST DISCLOSURE QUESTIONNAIRE

For Oklahoma Academy of Physician Assistants, Inc

This Questionnaire is to be completed by the Academy Officers, Directors, key employees, and members of Board committees.

The Annual Conflict of Interest Disclosure Questionnaire adopted by the Board of Directors of the Academy requires disclosure of certain interests. It is not uncommon to have these interests, but it is very important to make them known to the Academy.

Use this questionnaire to disclose where you or your Family Members have certain affiliations, interests or relationships, and/or have taken part in transactions that, in light of your relationship to the Academy, might possibly give rise to an actual, apparent, or potential conflict of interest.

Name(Required)

In accordance with the purposes and intent of the Conflict of Interest Policy and Code of Ethics Policy adopted by the Board of Directors of the Academy, a copy of which has been furnished to me, I hereby disclose that I or my Family Members have the following affiliations, interests or relationships, and/or have taken part in the following transactions:

1. BACKGROUND. Your role with the Academy.

2. OUTSIDE INTERESTS. Do you or any Family Member hold, directly or indirectly:

A) An ownership or investment interest in a company that does or may do business with, or that competes with, the Academy?(Required)
B) A compensation arrangement with any Company or entity that does or may do business with, or that competes with, the Academy? Examples: compensation for employment or independent contractor services, consulting fees, board stipends or fees, advisory committee fees, honoraria, etc.(Required)
C) A director, officer, or board committee position with any other Company that does or may do business with, or that competes with the Academy (including competition for grants or donations)?(Required)
D) Any personal loans, advances, or other indebtedness to or from anyone who also does or may do business with the Academy? (Note: You may exclude charge cards and personal or mortgage loans at market rates from financial institutions)(Required)
E) Do you or any Family Member compete, directly or indirectly, with the Academy in the purchase or sale of property rights, interests, or services?(Required)
F) Do you or any Family Member provide managerial, consultative, or other services to or on behalf of any other Company that does or may do business with, or that competes with, the services of the Academy?(Required)
G) Do you or any Family Member employ or otherwise retain any of the Academy personnel for work on non- Academy business done outside of the Academy?(Required)
H) Have you or any Family Member used the Academy property to conduct business that is not Academy business, without prior approval of an executive of the Academy?(Required)
I) If you are employed by the Academy, have you accepted assignments outside of the Academy, either as an employee or as an independent contractor, over and above your primary or full-time assignment with any Academy?(Required)
J) Do you or any Family Member hold an elected or appointed office or other position of public responsibility that serves residents in the Academy service area?(Required)
K) Have you or any Family Member been a party to any action, suit, or proceeding during the past five years that might be deemed material to evaluating your ability, your integrity, or your interests with respect to the Academy?(Required)
L) Do you or any Family Member know of any recent or pending actions, suit or proceeding in which you have an interest adverse to the interests of, or are a party adverse to the Academy?(Required)

3. INSIDE ACTIVITIES

A) In your area of direct responsibility within the Academy, do you employ or supervise anyone with whom you have a business or personal relationship?(Required)
B) Have you or any Family Member attempted to influence the Academy concerning the employment or retention of any immediate family member or other individual with whom you have a business or personal relationship?(Required)

4. GIFTS, GRATUITIES, AND ENTERTAINMENT

A) Have you or any Family Member accepted gifts or other favors from any person or company under circumstances from which someone might think that such action was intended to influence you in the performance of your duties on behalf of the Academy? Note: This does not prohibit the acceptance of reasonable items of nominal value that are clearly tokens of respect or friendship and not related to any particular transaction or activity when the value of such entertainment or items does not exceed One Hundred Dollars ($100.00).(Required)
B) Have you or any Family Member accepted any gifts, favors, or benefits valued in excess of One Hundred Dollars ($100.00) from customers, suppliers, or agents of the Academy?(Required)

5. OTHER

In the space below, please disclose any other interest, activities, investments, or involvement that you think might be relevant for full disclosure of all actual, apparent, or possible conflicts of interest.(Required)
Board Member Name(Required)
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