PLEASE READ CAREFULLY

Region/District Volunteer

Host Volunteer

Club or Organization
Volunteer (w/o coverage from group)

Unpaid College Student
As a person working with a State of Oregon agency, you need to understand the extent to which you are covered by State of Oregon self-insurance plan for tort liability and injury/illness. Please read the following carefully and sign on the reverse side.

Receiving Academic Credit
Student of Any Age NOT
Receiving Academic Credit
1. TORT LIABILITY You will be protected from civil liability for injuries or damage to the person or property of others, subject to the following general conditions:
1. You are working on a state agency task assigned by an authorized agency supervisor;
2. You limit your actions to the duties assigned, and
3. You perform your assigned tasks in good faith, and do not act in a reckless manner or with the intent to inflict harm to others.
The conditions and limits of this protection are as stated in the Oregon Tort Claims Act, ORS 30.260-300, and Oregon
Department of Administrative Services Risk Management Division Policy Manual, 125-7-202.
2.
MOTOR VEHICLE LIABILITY
/
PHYSICAL DAMAGE
,
UNINSURED MOTORIST
,
PERSONAL INJURY PROTECTION
If you use a personally owned vehicle in the course of your duties, you are required to have automobile liability insurance to provide primary coverage for any accidents involving that vehicle. State provided auto liability coverage may apply on a limited basis after your primary coverage limits have been used. Insurance certification must be provided to the
Oregon Department of Fish and Wildlife upon request. Coverage is provided in accordance to the Oregon Tort Claims
Act and the State’s Self Insurance Policy Manual.
The state does not provide physical damage, uninsured motorist, and personal injury protection for your vehicle. This means the state will not pay the costs of any repairs to your vehicle. It is up to you to carry physical damage, uninsured motorist and personal injury protection on your vehicle.
3. VOLUNTEER INJURY COVERAGE Workers’ Compensation is not provided. However, the agency has an injury protection plan to cover injuries of authorized volunteers. It is limited only to injuries resulting from an accident while performing volunteer duties. The state will pay medical expenses, disability, death and dismemberment benefits up to a total sum of $25,000 (maximum of $10,000 for medical expenses). This is a secondary insurance if you have your own insurance. If you are injured in a private vehicle, the owner’s automobile insurance is responsible for your medical bills.
As an authorized state volunteer performing activities on behalf of the State of Oregon, Oregon Department of Fish and Wildlife, I understand that the State of Oregon will provide limited medical and accidental death, dismemberment and disability coverage for me in the event I suffer injury due to an accident while performing volunteer duties. In exchange for the coverage, I, for myself, my heirs, executors, administrators and assigns, release and forever discharge the State of Oregon from any and all demands or claims for damage or injury, from any cause of suit or action, known or unknown, that I may have against the State of Oregon, and/or its officers, agents or employees, and from all liability under the Oregon Tort Claims Act, ORS 30.260-300, for any and all harm or damage to my health in any manner resulting from or arising out of my state volunteer activities.
This release does not extend to or waive any rights I may have under the Oregon Tort Claims Act, ORS 30.260-300, to defense and indemnification from any demand, claim, suit or action brought against me, or liability I may be subject to, or arising out of my authorized state volunteer activities.
In the event that I am injured while performing state volunteer activities, I will notify my agency supervisor and apply for injury coverage benefits.
4. PERSONAL PROPERTY / HEAVY EQUIPMENT If you use personally owned or hired property in the course of your duties
(including heavy equipment), it is up to you to carry insurance on that property. The state does not provide personal property damage protection or personal injury protection for other than state owned or hired heavy equipment and other personal property. This means the state will not pay the cost of repairs to heavy equipment or other personal property. Proof of insurance must be furnished upon request.
5. REPORTING RESPONSIBILITY Any time you are involved in any accident or exposed to a potential liability situation while performing assigned duties, you must inform the agency supervisor as soon as possible

A. ASSIGNED DUTIES
Are limited to only those duties assigned by your ODFW supervisor or as listed in your volunteer job description.
 Yes  No Will drive a state vehicle as part of duties. If yes, coverage is provided under the state auto insurance coverage. Volunteer must be 18 years or older, possess a current drivers license and have a volunteer application and 3 or 5 year driving record on file.
B. I HAVE READ AND UNDERSTAND THE ABOVE DUTIES AND THE CONDITIONS OF VOLUNTEER SERVICE. I
HAVE ALSO READ THE VOLUNTEER CODE OF CONDUCT AND UNDERSTAND HOW IT APPLIES TO MY
VOLUNTEER ACTIVITIES FOR ODFW.
Volunteer Name (type or print clearly)
Volunteer Signature Date
Parent or Legal Guardian Signature Date
(Parent or guardian signature required if volunteer is under age 18. Also see section C below.)
Address
Email
City State
Birthdate
Day Phone
In case of emergency, please notify
Address
Name
Evening Phone
City State
Day Phone Evening Phone
C. FOR MINORS ONLY: EMERGENCY MEDICAL RELEASE READ CAREFULLY!
Zip
Zip
PARENT OR GUARDIAN’S AUTHORIZATION FOR MEDICAL CARE AND CONSENT TO AGREEMENT
I, , as parent or legal guardian, hereby grant permission for
to do volunteer field work for the Oregon Department of Fish and Wildlife. In the event of an emergency, accident, or illness, I authorize the agency and its employees to administer emergency medical care to my child and/or, if deemed necessary, to secure emergency medical services and incur expenses for which I will be responsible for payment. My signature below hereby represents that I have read, understand, and consent to this agreement.
Signature of Parent or Legal Guardian: Date
D. AGENCY SUPERVISOR SECTION: Supervisor: You must fill out this section and the assigned duties section.
Agency Supervisor
Station/Location
Phone
Date
 Region/District Volunteer  Host Volunteer  Club or Organization Volunteer (w/out coverage from group)
 Unpaid College Student Receiving Academic Credit  Student of Any Age NOT Receiving Academic Credit

 Before the volunteer fills out the form, the agency supervisor must fill out Sections A & D. It is important that the CVS form be completed correctly in case of accident or emergency. Keep a copy of the CVS form at the project site.
 Volunteers should fill out an updated CVS form once per calendar year. If their job duties change within the year, it should be noted on the form, or they should fill out a new one.
 Make a copy for yourself and send the original to your District or Regional Volunteer Coordinator.
 Make sure the volunteer is provided the CVS form and the Volunteer Code of Conduct. He is signing that he has read both forms.
SECTION A: ASSIGNED DUTIES
PLEASE READ THE REVERSE SIDE OF THIS DOCUMENT AND THE
VOLUNTEER CODE OF CONDUCT CERTIFICATION FORM BEFORE SIGNING.
FORM A
A. ASSIGNED DUTIES
Are limited to only those duties assigned by your ODFW supervisor or as listed in your volunteer job description.
Yes No Will drive a state vehicle as part of duties. If yes, coverage is provided under the state auto insurance coverage. Volunteer must be 18 years or older, possess a current drivers license and have a volunteer application and 3 or 5 year driving record on file.
B. I HAVE READ AND UNDERSTAND THE ABOVE DUTIES AND THE CONDITIONS OF VOLUNTEER SERVICE. I
HAVE ALSO READ THE VOLUNTEER CODE OF CONDUCT AND UNDERSTAND HOW IT APPLIES TO MY
VOLUNTEER ACTIVITIES FOR ODFW.
Volunteer Name (type or print clearly) ____________________________________________________________
The ODFW supervisor completes this section.
It is strongly recommended that volunteers have written job duties whenever possible. If the volunteer will be involved in high risk or specific limited activities
(e.g., operate a chain saw, drive a state vehicle, or post signs only on John Doe’s property), these activities are
required to be clearly listed in this section.
Volunteer Signature __________________________________________________ Date ___________________
Parent or Legal Guardian Signature _____________________________________ Date ___________________
(Required if volunteer is under age 18. Also see section C below.)
Address ________________________________________________________ City _______________________
State____________ Zip ___________ Email_____________________________ Birthdate__________________
Day Phone ( )___________________________ Evening Phone ( )_____________________________
In case of emergency, please notify ____________________________________________________________
Address____________________________________ City______________ State__________ Zip ____________
Day Phone ( )___________________________ Evening Phone ( )_____________________________
C. FOR MINORS ONLY: EMERGENCY MEDICAL RELEASE
PARENT OR GUARDIAN’S AUTHORIZATION FOR MEDICAL CARE AND CONSENT TO AGREEMENT
READ CAREFULLY
I, , as parent or legal guardian, hereby grant permission for
to do volunteer field work for the Oregon Department of Fish and
Wildlife. In the event of an emergency, accident, or illness, I authorize the agency and its employees to administer emergency medical care to my child and/or, if deemed necessary, to secure emergency medical services and incur expenses for which I will be responsible for payment. My signature below hereby represents that I have read, understand, and consent to this agreement.
Signature: Date
(Legal guardian signature required if participating person is under age 18 years)
D. AGENCY SUPERVISOR SECTION: Supervisor: You must fill out this section and the assigned duties section.
Agency Supervisor ________________________________ Telephone ( ) _________________
Station/Location __________________________________________ Date _________________

All volunteers should be given clear and specific verbal and written instructions as to their duties and limits, safety considerations and training. If provided specific safety training, document the date, describe the training in writing, and have the volunteer initial that they have received such training and have had the opportunity to ask questions. If there is not enough room on the form, please attach a job description or list of duties to the form.
Also make sure to check YES or NO to show whether or not the volunteer will be driving a state vehicle as part of his duties. If YES there are certain forms and conditions that must be met. These are listed on the
CVS form.
SECTION B: SIGNATURE & CONTACT INFORMATION
Must be signed by the volunteer or the volunteer’s parent or legal guardian if the volunteer is under age 18. Please have the volunteer or parent complete all the information in this section. It is used to put the volunteer onto the database to receive information and mailings. It also supplies information on who to contact in case of an emergency. A copy of this form should be kept at the job site.
SECTION C: EMERGENCY MEDICAL RELEASE
Must be filled out by a parent or legal guardian if the volunteer is a minor. Any person under the age of 18 is considered a minor. Keep a copy of this form with you at the work site. If a minor is taken to any medical facility for treatment this form must accompany them.
SECTION D: AGENCY SUPERVISOR SECTION
The ODFW supervisor completes this section. This information is used to track what project or program the volunteer is working with and for obtaining follow-up information on the volunteer if it is needed.