Acknowledgement of Risk and Waiver of Liability - American Dental Association

I, the Undersigned Volunteer, desire and agree to volunteer for the American Dental Association Mission of Mercy to be conducted in New Orleans, Louisiana in 2013 (the "Mission") as sponsored by the American Dental Association (“ADA”) and America’s Dentist’s Care Foundation (“ADCF”) (ADA, ADCF and the ADA Mission of Mercy are hereinafter referred to collectively as "ADA MOM"). I understand and agree as follows:

1. I, personally and on behalf of my heirs, representatives, assigns and anyone else entitled to claim through me, hereby waive any right of recovery, and waive, release, hold harmless and forever discharge ADA MOM, their officers, trustees, officials, employees and agents, and other volunteer dental service providers, from liability related to and/or arising from any and all injury to persons, damage to property or otherwise in connection with my participation in the Mission.  I further agree and undertake to hold harmless ADA MOM 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 the Mission.

2. I further acknowledge and agree that ADA MOM assumes no responsibility whatsoever for my property and that I shall not hold ADA MOM liable for any loss or damage to same.

3. I understand and acknowledge that ADA MOM neither carries nor maintains, and expressly disclaims any responsibility for providing, health, medical or disability insurance for my benefit.  I understand and acknowledge that I am to obtain and am responsible for my own insurance coverage.

4. I grant ADA MOM and their agents the right to use without payment or consideration of any kind, my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing the Mission, its services and its activities in all forms of media in perpetuity.

5. I undertake to perform said services as a volunteer without compensation and acknowledge that in performing said services I am acting solely as a volunteer and not as an employee of ADA MOM.

6. If I am a dental or medical service care provider, I hereby certify: that I am licensed to perform the types of dental or medical services and treatments I am expected to perform and that are being offered through the Mission volunteers in the State of Louisiana. I have indicated below my license number and the state in which it is effective and certify to ADA MOM, by execution of this Waiver, that such license is current, valid and in good standing.  I understand and agree that, if I am not licensed to perform the dental or medical services and treatments I will be required to perform in the state of Louisiana, ADA MOM may request a provisional license for me to practice in the state of Louisiana for purposes of the Mission. I further understand and agree that if I do not have a valid license or provisional license at the time of the Mission, I will not undertake to perform any services or treatments I am, by virtue of the lack of license or provisional license, unable legally to perform. I understand and acknowledge that I must and do, at a minimum, have in place and will have in effect during the dates of the Mission the following insurance coverages, which cover my participation in the Mission: Professional Liability insurance, with $1 million per occurrence and $3 million aggregate limits.

7. I will comply with all applicable federal, state, and local laws relating to the practice of dentistry generally and specifically in the state of Louisiana, including but not limited to laws concerning informed consent and patient privacy and confidentiality.

8. I understand and agree that if I, as a volunteer, am exposed to a needle stick or sharp exposure,I will be taken to the local Mission chairman to have the testing protocol explained once the immediate steps of rinsing out the site have been completed. I understand that I will then be given the choice to be tested and that I have the right to refuse testing. If I do so refuse, I understand that I will be required to sign and indicate on an Incident Report form that I have refused care/testing. I understand and agree that any testing performed on me will be at my own expense.