Donate Life Ambassador Application 

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Thank you for your interest in becoming a Donate Life Ambassador (volunteer) with Donor Network West. Please complete and submit this form.  Please note that background checks are performed on all potential volunteers.

Once we receive your application, you will receive further instructions regarding additional paperwork which needs to be completed, signed and submitted. In addition, there is a required training prior to volunteering.

Thank you in advance for your support, time and efforts. You give hope to thousands who wait for a second chance at life.

Background Check Authorization
I understand that a background check is performed on all potential volunteers.  By choosing "Yes" and entering my initials in the box below, I authorize Donor Network West to run a criminal and sex offender background check without liability to Donor Network West. I further understand that acceptance of my application is contingent on allowing Donor Network West to run a background check.
You will receive a separate email from Candidate Portal (SterlingOne/Talentwise) with a link to your background check form. You will have 7 days to complete. Please don't delay in submitting the form, as we can't accept your application without clearance, and you would be unable to participate in our volunteer opportunities.
Declined Background Check Authorization
Thank you for your interest in volunteering with Donor Network West.  Unfortunately, without a cleared background check, we are unable to allow you to participate in any volunteer opportunities.

If you have any questions, you can contact
Contact Information
About You
Please check all that apply
Your Connection to Donation
For Donor Families & Friends

Please share your loved one's name, age at time of donation, and your relationship to them; as well as any other information you would like to share here.
For Recipients, Family & Friends
If you are not the recipient, please share the recipient's name and your relationship to them; as well as any other information you would like to share here.
For Living Donors, Family & Friends
If you are not the living donor, please share the living donor's name, your relationship to them, and who they donated to; as well as any other information you would like to share here.
For Those Waiting, Family & Friends
If you are not the person waiting, please share the transplant candidate's name, age, and your relationship to them; as well as any other information you would like to share here.
Family/Friend of someone who died waiting for a transplant
Please share your loved one's name and your relationship to them; as well as any other information you would like to share here.
For Supporters of Donation
If you do not have a direct connection to donation, please share why you would like to become a volunteer with Donor Network West.
Your Volunteer Interests
Please select all that apply
Your Community Connections
Please select all that apply and specify in the fields below.

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Please read carefully and sign off on the sections below which outline our policies for 
volunteers joining Donor Network West.
News Media, Promotional Materials, Written Articles, Photographs and/or Video Consent
     I hereby authorize the use of photographs, video and/or the public release of information regarding the donation, recovery and/or transplant of organs and/or tissues by Donor Network West for permitted uses, e.g., dissemination to Donor Network West of hospital staff, physicians, health professionals, and members of the public for educational, treatment, research, scientific, public relations, marketing, news media, and charitable purposes.
     I warrant that I am over the age of eighteen (18) and otherwise authorized to release the use of photographs, video and/or information regarding the donation, recovery and/or transplant of organs and/or tissues to Donor Network West for the permitted uses. I authorize the use or disclosure of such photographs, videos and/or information in order to assist scientific, treatment, educational, public relations, marketing, news media, and charitable goals, and I hereby waive any right to compensation for such uses by reason of the foregoing authorization. I and my successors or assigns hereby hold Donor Network West, its employees, officers and agents, and their successors or assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.
     I may rescind this Authorization up until a reasonable time before any photographs, video or information are used, but I must do so in writing and submit it to: Donor Network West, 12667 Alcosta Blvd, Suite 500, San Ramon, CA 94583.
     I have a right to receive a copy of this Authorization.
     Information disclosed pursuant to this Authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPAA).
Volunteer Corporate Compliance, Confidentiality statement and Conflict of Interest Disclosure
     I understand that I might come into possession of, or have access to, a broad variety of confidential, sensitive, and proprietary information, of which the inappropriate release could be injurious to individuals, Donor Network West's business partners, and Donor Network West itself. I have an obligation as a volunteer to actively protect and safeguard confidential, sensitive, and proprietary information in a manner to prevent its unauthorized disclosure.
     I have an obligation to conduct myself in accordance with all Donor Network West policies and procedures concerning the confidentiality of patient information and in accordance with all applicable laws and regulations. I will refrain from revealing any personal or confidential information concerning patients or their family members unless supported by legitimate business. If question arise regarding an obligation to maintain the confidentiality of information or the appropriateness of releasing information, I will seek guidance from the Volunteer Program management.
     I must exercise care to ensure that intellectual property assets of Donor Network West, including patents, trademarks, copyrights, and software is carefully maintained and managed to preserve and protect its value.
     If my responsibilities authorize me to be privy to confidential information, I will exercise care to prevent the release or sharing of such information to ensure confidentiality in accordance with applicable laws.
     I also understand that it is against Donor Network West policy to seek out of use personal or confidential information relating to Donor Network West, its business partners or clients for my own interest or advantage.
     I am advised that failure to comply with these policies may result in disciplinary action, which could include release from participation in the Volunteer Program. Violation of local, State of California, or United States federal statutes may carry the additional consequence of prosecution under the law, where judicial action may result in specified fines or imprisonment, or both, plus the costs of litigation, the payment of damages, or both, or all.
     I understand my responsibility to notify Volunteer Program management if my situation changes and a need for disclosure makes it necessary to provide a revised form.
Volunteer Commitment 
I have read the guidelines and agree to be an "Active Volunteer" by committing to at least 4 events or activities per calendar year and completing training every 2 years. If I cannot meet this obligation, I understand that my name will be removed from the Donate Life Ambassadors program until I can make the minimum commitment.