Liability and Insurance Guidelines and Waiver

All volunteers MUST READ and INITIAL indicating they have read, in full, all liability and insurance information below that is specific to their volunteer type.

Yes, we are trying to do good, and that includes doing good by all of our sponsors, volunteers and associates. We ask that you read the service agreement below in its entirety and gain a full understanding of its meaning. You will not be able to submit your volunteer registration until you check and initial indicating that you have read and agree to this waiver.

IndianaMoM Volunteer Service Agreement – Waiver of Liability (Healthcare)

FOR HEALTHCARE VOLUNTEERS, by initialing the ‘I Agree’ statement on the volunteer registration form, I, on behalf of myself and all persons claiming under, by or through me, in consideration of being allowed to participate as a volunteer in the Indiana Mission of Mercy Event (IndianaMoM), waive any right of recovery and release the Indiana Dental Association Foundation for Dental Health, Inc. (IFDH) and the Allen County War Memorial Coliseum, their affiliates, officers, officials, employees and agents, from liability, arising from any and all injury to persons and damage to property, including, but not limited to those which arise out of NEGLIGENCE of any of the above entities or individuals, and further agree and undertake to indemnify, hold harmless and defend the above entities and individuals from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services at the above IndianaMoM.

I, as a volunteer, further acknowledge and agree that IFDH and the Allen County War Memorial Coliseum do not assume any responsibility whatsoever for my property and I shall not hold IFDH or the Allen County War Memorial Coliseum liable for any loss or damage to same.

I, as a volunteer, further acknowledge and grant to IFDH and its agents the right to use my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing IndianaMoM services and its activities in all forms of media in perpetuity.

I, as a volunteer, further acknowledge that I hold an active or volunteer Indiana license or a license or registration in another state to practice in the category of professional service for which I volunteered for the IndianaMoM event as a dentist, dental hygienist, expanded function dental assistant, physician, physician’s assistant, LPN, RN, nurse’s aide, EMT, pharmacist, or pharmacy tech or any other healthcare position.

I state and affirm that my license has not been revoked suspended or subject to probation and that I am not currently restricted from practicing the profession for which I have volunteered for the IndianaMoM event in any way in Indiana or in any other state in which I am licensed or registered. I also hereby state and affirm that I am not aware of any current or pending investigation relating to my license or registration to practice in Indiana or any other state in which I am licensed or registered.

I further represent and warrant to IFDH that neither I nor any entity in which I am an owner, officer, director, manager, or employee is excluded from participation in any federal health care programs, as defined under 42 U.S.C. 1320a-7b(f), or any form of state Medicaid program, and to my knowledge, there are no pending or threatened governmental investigations that may lead to such exclusion. I agree to notify IDA and IDAF of the commencement of any such exclusion or investigation within seven (7) business days of my first learning of it.

IndianaMoM Volunteer Service Agreement – Waiver of Liability (General)

FOR GENERAL COMMUNITY VOLUNTEERS, By initialing the ‘I Agree’ statement below, I, on behalf of myself and all persons claiming under, by or through me, in consideration of being allowed to participate as a volunteer in the IndianaMission of Mercy (IndianaMoM) event, waive any right of recovery and release the Indiana Dental Association Foundation for Dental Health, Inc. (IFDH) and the Allen County War Memorial Coliseum, their affiliates, officers, officials, employees and agents, from liability, arising from any and all injury to persons and damage to property, including, but not limited to those which arise out of any aspect of my participation in IndianaMoM, including, particularly, the actions, inactions, carelessness, or NEGLIGENCE of any of the above entities or individuals, and further agree and undertake to indemnify, hold harmless and defend the above entities and individuals from and against any and all claims, damages, actions, liability and expenses including attorney’s fees and other professional fees in connection with bodily injury including death, personal injury and/or damage to property arising from or out of my activities and participation in volunteer services at the IndianaMoM.

I do further acknowledge and agree that IFDH and the Allen County War Memorial Coliseum do not assume any responsibility whatsoever for any property of mine and I shall not hold IFDH or the Allen County War Memorial Coliseum liable for any loss or damage to same.

By initialing the ‘I Agree’ statement below, I also grant to IFDH and its agents the right to use my picture, voice, and other reproductions of my physical likeness in connection with advertising or publicizing the IndianaMoM services and its activities in all forms of media in perpetuity.

INFORMATIONAL: Out-of-State Healthcare Volunteers – Gratuitous Services, Temporary License Status

Notwithstanding any other provision of law to the contrary, any qualified dentist who is legally authorized to practice pursuant to the laws of another state may practice as a dentist in this state without examination by the board or payment of any fee and any qualified dental hygienist who is a graduate of an accredited dental hygiene school and legally authorized to practice pursuant to the laws of another state may practice as a dental hygienist in this state without examination by the board or payment of any fee, if such dental or dental hygiene practice consists solely of the provision of gratuitous dental or dental hygiene services provided for a period of not more than fourteen days in any one calendar year. Dentists and dental hygienists who are currently licensed in other states and have been refused licensure by the state of Indiana or previously been licensed by the state, but are no longer licensed due to suspension or revocation shall not be allowed to provide gratuitous dental services within the state of Indiana. Any dental hygiene services provided pursuant to this section shall be performed under the supervision of a dentist providing dental services pursuant to this section or a dentist licensed to practice dentistry in Indiana.

The board may not issue any temporary certificates of registration or licenses to practice dentistry in Indiana; except, upon the request and recommendation of the department of health and senior services, the department of mental health, or the department of corrections and human resources, the board shall issue a letter authorizing an uncertificated and unlicensed graduate of an accredited dental school to practice dentistry if the board determines that the recommended person is qualified to take the dental examination and if this person is employed by an institution operated by one of the aforenamed agencies the letter shall be effective for such period of time as may be authorized by the board, but any such authorization issued by the board shall in no event extend beyond the date that the results of the board’s dental examination or examinations next following the date of the authorization are announced.