Preceptor Application Form

Your Personal Information

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Waiver Agreement

Thank you for your interest in becoming a preceptor with SHINE, University of Alberta. SHINE is operated by students from the various health faculties at the University of Alberta. The University recognizes that your contribution enhances the University’s programs and activities, and wants to ensure that your experience is a safe and rewarding one.

BY SIGNING THIS FORM, YOU GIVE UP IMPORTANT LEGAL RIGHTS! PLEASE READ CAREFULLY!

TO: THE GOVERNORS OF THE UNIVERSITY OF ALBERTA (the University)

In consideration of my volunteer work, I understand that I am not entering into an employment relationship with the University of Alberta. For my volunteer services I am in no way entitled to receive a salary or any employee benefits.. I understand that my duties and responsibilities have been explained in detail. I understand that either the University or myself may terminate this volunteer relationship at any time without notice. I also understand that I must familiarize myself with, and adhere to, all applicable University of Alberta policy and procedures, including (without limitation) obligations respecting confidentiality. I further confirm that any of my volunteer work and related practice at SHINE: i) falls within my scope of my professional license, which is valid, current, and in good stranding, and ii) is covered under my own medical malpractice insurance.

ASSUMPTION OF RISK

I acknowledge that I am aware there are risks associated with or related to the duties described above that I will be required to perform. These risks include, but are not limited to:

1. The risks associated with travel to and from locations where my duties will be performed including transport by public or private motor vehicle, bus, train, or other alternate transportation system.
2. Any manner of injury resulting from use or misuse of equipment/tools required to perform my duties.
3. Any manner of physical or mental injury (including death) that could result from being on University of Alberta property, at the Boyle McCauley Health Clinic, or at any other site while carrying out my SHINE volunteer duties.
4. Transmission of diseases in various ways and types from contact with SHINE patients and other participants resulting in death, disease or other illness.

I freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury, death, permanent disability, property damage or loss resulting thereof.

MEDICAL/HEALTH INSURANCE, OTHER PERSONAL INSURANCE and UNIVERSITY OF ALBERTA INSURANCES

I AM SOLELY RESPONSIBLE to select and purchase adequate medical/health insurance. No medical/health insurance will be provided by the University of Alberta. In the event of a medical/health problem, the University of Alberta accepts no responsibility for any costs associated with a medical/health problem nor will they pay for any medical/health expenses which may be incurred by the Preceptor.

The University does not insure personal vehicles or property for either employees or volunteers. Preceptors who bring personal property with them or who will be driving their own personal vehicles on University business are urged to contact their insurance broker to ensure that they have adequate personal automobile and property insurance.

By signing this agreement, the University considers you as a “registered volunteer” and you will be covered by the University’s general liability insurance policy. This means that while properly carrying out your preceptor responsibilities as outlined in the “SHINE Preceptor Information” you are insured against liability claims from third parties for property damages, bodily injury and personal injury as long as you have not willfully, maliciously or with real intent caused the injuries.

I freely accept and assume all responsibility to provide myself with medical/health insurance, personal insurance and travel insurance coverage (if necessary).

WAIVER AND RELEASE OF LIABILITY

I hereby release the University from liability for any loss, damage or injury (including death), which I may sustain as a result of my preceptoring duties as noted above, including any loss, damage or injury caused by the negligence of the University. I agree to be solely responsible for any such loss, damage or injury.

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act, and will be protected of that Act. It will be used for the purpose of effecting this SHINE Preceptor Agreement.