In offering my services for the Colorado Public Health and Medical Volunteer System ("Volunteer System"), I understand, agree and state:

1. I certify that all statements made in this application are true. Any misstatement of material facts may cause forfeiture of my eligibility to serve as a volunteer. Any falsification or omission of information may result in my removal as a volunteer.

2. I agree to provide necessary health and identification information as may be required for my participation in the Volunteer System, which the Colorado Department of Public Health and Environment ("CDPHE") may disclose to other federal agencies, states agencies, regions or municipalities, or other volunteer organizations assisting in the response as may be necessary to prepare for and respond to emergencies.

3. I authorize the release of information necessary for the CDPHE and its contractors to check any information regarding my background, including references, licensing credentials, and criminal records.

4. I agree to perform my volunteer services and activities under the terms, conditions and general direction of the CDPHE or the governmental entity taking the lead in responding to the emergency event, and under the supervision of the designated government official.

5. I agree to maintain in good standing my current health professional licensure or certification registration, as may be applicable.

6. I waive any claims for compensation from the State of Colorado, CDPHE or the sponsoring governmental entity for my volunteer services performed as a part of the Volunteer System.

7. I understand that I may be immune from liability, or that my liability may be limited, under the Colorado Governmental Immunity Act, the Colorado Volunteer Service Act, or other applicable statutes for damages or injuries that I may cause through acts or omissions in my volunteer assignment so long as:

A. I am acting under the supervision of the designated government official and within the scope of my volunteer assignment and responsibility;

B. I am properly licensed, certified or authorized by the appropriate governmental authorities; and

C. I have not engaged in any willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious, flagrant indifference to the rights or safety of the individuals who may be harmed by me.

8. I understand that I may be eligible for workers compensation benefits for work related injuries and/or illnesses that may arise and are directly related to the performance of my volunteer assignment, ONLY IF ONE OF THESE CIRCUMSTANCES APPLIES:

A. My volunteer assignment is within the course and scope of duties of my regular employment, in which case my employer's workers compensation coverage may apply;

B. My volunteer service is one of the enumerated volunteer activities set forth in C.R.S. § 8-40-202(1)(a) such as volunteer rescue teams or groups, volunteer disaster teams, or volunteer ambulance teams or groups, or

C. I perform volunteer services during a declared disaster and:

1) I am a physician, health care provider, public health worker, or emergency medical service provider who is ordered by the Governor or a member of the disaster emergency forces of this State to provide specific medical or public health services during and related to an emergency epidemic and I comply with such an order without pat or other compensation, or

2) I have registered with the Division of Emergency Management or a with a local organization for civil defense, and

3) The General Assembly appropriates funds to pay for such workers compensation benefits, as provided by C.R.S. § 24-32-2206.

9. If my personal vehicle is to be used while on State business, it must carry liability insurance pursuant to State law. The limits of liability should be those outlined in the Colorado Governmental Immunity Act, e.g., $150,000 and $600,000 per accident. The State provides liability coverage for volunteers in a personal car on an excess basis. My insurance is the primary insurance. The State will not pay for collision damage to a personal vehicle being used for State business.

10. The Agreement may be terminated at any time without cause by either party, upon advance written notice, except that the State may terminate this Agreement immediately upon good cause.