Fillable University of North Georgia Non-Paid Affiliate or Volunteer (University of North Georgia)

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University of North Georgia Non-Paid Affiliate or Volunteer (University of North Georgia)

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University of North Georgia
Non-Paid Affiliate or Volunteer Information Form
(Please print legibly and provide all information requested)
Name: ________________________________ ___________________________________ _______
Last First MI
SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date of Birth _____/_____/_____ � Male � Female
(SSN and Date of Birth are required for access to university services and will not be used for any other purpose)
__________________________________________________
Permanent Street Address
__________________________________ ______ ________
City State Zip Code
Email: _____________________________________
Phone:
( __ __ __) _____________________________________
Person to notify in emergency:
______________________________
Name
______________________________
Phone
____________
Relationship
Have you previously worked for the University of North Georgia?
�
Yes
�
No
Will your duties as an unpaid affiliate include any programs or activities with non-enrolled minors? � Yes � No
Will your duties require you to have a UNG email account? � Yes � No
I attest that I am freely, without pressure or coercion, giving my time and services to the University of North Georgia as an affiliate,
associate or other individual working in an unpaid status. I am working in a non-salary or wage capacity solely for affiliation,
educational, or personal reasons and without expectation of compensation, benefits or future employment from the University
beyond any specified reimbursement arrangements, outside stipend or affiliate agreements.
I agree to familiarize myself with, and abide by, UNG rules and policies regarding conduct, confidentiality, safety and welfare. I
understand that I may be subject to the same pre-employment screening and criminal background checks as paid
employees performing similar duties.
I understand that the State of Georgia provides general liability coverage to volunteers, but no other university or state-
sponsored employee medical, retirement, workers compensation, or other insurance plans apply to this association. I understand
that UNG and I both have the right to end the volunteer relationship at any time, for any reason, without advance notice.
I understand that if I am issued a university access card it is the property of the university and is issued at the university’s sole
discretion. I will not represent myself as a university employee, and I understand that the university may revoke my access to
its facilities and/or require that I return the card at any time for any reason.
My signature below affirms that all information on this information form is accurate to the best of my knowledge and I agree to
abide by the conditions outlined above.
Signature: ______________________________________________________ Date: ____/____/____
Assignment Begin Date: ____/____/____ Assignment End Date: ____/____/____
(Note: University Affiliate assignments are effective for current assignment or up to one year, whichever comes first.)
This form must be forwarded to Human Resources after completion.
HR Review by: ____________________________________________
BANNER #: ______________________________
HCM ID #: _______________________________ Date: ____/____/____
*Note: This form must accompany the Volunteer Registration Agreement.
UNG is committed to ensuring that this form is accessible to everyone. If you have any questions or suggestions
regarding the accessibility of this form, please contact Michael McLeod – 678.717.2232
Revised 3/28/2019
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1 Revised 3/28/2019
VOLUNTEER REGISTRATION AGREEMENT
Volunteer’s Name (Please Print):__________________________________________________
Dates of Service: From Date ______________________ until Date ______________________
Sponsoring Department: ___________________________________________
Supervisor of Volunteer: ___________________________________________
Purpose for Volunteer Service: ___________________________________________________
Scope or Volunteer’s Work & Duties:
____________________________________________________________________________
____________________________________________________________________________
As a Volunteer, I understand and agree to the following:
1.
I am volunteering to perform the volunteer duties identified above solely for my personal benefit without
promise or expectation of compensation, benefits, academic credit, or future employment from University
of North Georgia (“University”). I acknowledge that, in exchange for my service as a volunteer, I have neither
been promised any consideration nor do I expect to receive any consideration, except as indicated in
Paragraph 8.
2.
I understand that the University and/or I may end my volunteer services at any time without further obligation
one to the other, and for any reason, and without advance notice. I understand and agree that as a
volunteer, I will not be acting as a University employee or student.
3.
I will familiarize myself with and abide by all University policies, including those regarding conduct,
confidentiality, safety and welfare. I agree to abide by all applicable rules and regulations of the University
and any of the departments or units where I engage in volunteer activities.
4.
I agree to perform my volunteer duties under the direction and control of the authorized University official
identified above or such other authorized University official as is later designated to supervise my volunteer
work.
5.
I agree to cooperate with any screening and background checks required by the University prior to my
performance of any volunteer duties.
6.
I understand that volunteers are not covered by workers’ compensation insurance for injuries or illness
resulting from their volunteer activities, and are strongly encouraged to obtain their own medical
insurance before participating in this structured volunteer program. I understand that the University will
not provide me with accident or medical insurance, and is not responsible for any accident or medical
expenses that I incur in the course of volunteering.
7.
I understand that my participation as a volunteer may involve certain risks that have been explained to
me, including, but not limited to __________________________________________________________
___________________________________________________________________________________,
I voluntarily accept these risks.
2 Revised 3/28/2019
8.
I further understand that during the volunteer period designated above, I agree to serve as
a volunteer with University of North Georgia by participating in the structured volunteer program
organized, controlled, and directed by University of North Georgia as described in the description of
duties above, which are for the sole purpose of carrying out the functions of University of North
Georgia. In consideration for my service as a volunteer, the University of North Georgia agrees that
I am a “state officer or employee” solely for the purpose of
O.C.G.A. § 50-21-20 et seq. (Georgia Tort Claims Act) as long as I act within the scope of service set
forth in this Agreement.
9.
If my Volunteer Duties involve assisting with research:
• I understand and agree that federal laws regulating the export of technologies may prohibit
assistance by international individuals on certain types of research projects. I understand that all
University and other required approvals must be secured prior to conducting research activities
and I agree to abide by all policies and procedures governing such activities. If I assist with
research funded by a third party sponsor, I agree to abide by the terms of the sponsorship
agreement. Further, I agree to be bound by any written nondisclosure or confidential disclosure
agreement governing confidential information to which I may have access in the course of my
research activities at University.
• I pledge to disclose any intellectual property developed as a result of my research activities at
University. If valuable intellectual property is created as a result of the research with which I
assist at University, then ownership of such intellectual property shall be determined by University
policy and federal law regarding inventorship and authorship.
• I agree not to disclose any confidential information concerning patients, research subjects,
unpublished research data, and other confidential information of which I may learn in the course of
my volunteer service.
10.
My performance of the Volunteer Duties is purely voluntary and I agree to assume all risk associated
therewith. I do hereby release, waive, discharge and covenant not to sue the University of North
Georgia and the Board of Regents of the University System of Georgia their members individually
and their officers, directors, agents, trustees, board members, employees, volunteers, contractors,
representatives, successors, and assigns, individually and in any capacity (collectively, the
“University”) from all liability, loss, damage, costs, expenses, or claims resulting from or in connection
with my volunteer status or duties, including personal injury, death, or damage to property arising out
of my volunteer activities. I also agree to indemnify and hold the University harmless from all claims,
demands, causes of action, actions, judgments or other liability including reasonable attorneys’ fees
arising out of, resulting from or in connection with my volunteer status or duties.
Department Head Name: _______________________________________________________
Signature: ___________________________________________________________________
Supervisor Name: _____________________________________________________________
Signature: ___________________________________________________________________
Volunteer Name: ______________________________________________________________
Signature: ___________________________________________________________________
* This form must accompany the Non-paid Affiliate or Volunteer Form
UNG is committed to ensuring that this form is accessible to everyone. If you have any questions or
suggestions regarding the accessibility of this form, please contact Michael McLeod - 678.717.2232
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Completed 16 August 2020

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