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OFFICE OF RISK MANAGEMENT
Agreement for Non-reimbursed Volunteer Services
DEPARTMENT NAME:
VOLUNTEER NAME:
This agreement is between the ϻ, department of
___________________________________________________________ and
________________________________________________ (name of volunteer)
for services rendered as __________________________________________.
Description of Services
The above-named individual is not a regular employee of the above-named department and the work to be performed will not replace the work of regular employees of the department.
It is understood that the services are voluntarily offered for the time period from ________________ ______ (date) to ___________________________ (date), and that these volunteer services are not to be reimbursed. Approximate number of hours that will be spent in the volunteer services by this individual in total: ____________ (# of hours).
Does the volunteer currently carry any primary medical insurance?
______ (YES) ______ (NO)
If YES, please provide the name of your primary insurance provider.
____________________________________________________________________
________________________________ ____________________
Volunteers Signature Date
________________________________ ____________________
Supervisors Signature Date
________________________________ ____________________
Department Approval Date
Note: These volunteer services provided for the ϻ are not covered by the workers compensation policy of the ϻ.
Please return completed form to: Office of Risk Management, Attn: Jason Sloat, Risk Manager, ϻ, 32 Campus Drive, Main Hall, Missoula, MT 59812-1800
Contact for Questions: Jason Sloat at 406-243-2700 or email: HYPERLINK "mailto:Jason.Sloat@mso.umt.edu" Jason.Sloat@mso.umt.edu
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