Name *

First Name

Last Name

Gender *

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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Alignment with Seventh-day Adventist Church *

I understand that this is a program implemented by Seventh-day Adventists to support the mission of the worldwide Seventh-day Adventist church. I agree to not share with patients/guests ideas or beliefs that are not aligned with the 28 fundamental beliefs of the Seventh-day Adventist church.

Yes

Alignment with Adventist health message and lifestyle medicine *

I understand that this program aligns with the health principles of the Seventh-day Adventist church and lifestyle medicine, including a plant-based diet and abstinence from alcohol, caffeine and tobacco. The program also does not support health practices based on mystical or energy systems, including yoga, reiki, homeopathy, and eastern meditation/medicine. I agree to refrain from sharing or promoting to patients/guests information that do not align with with the health principles outlined here.

Yes

I agree to abide by the following dress code. I understand that the intention of this dress code is to be professional, represent Christ in our appearance and minimize distractions. *

* No jewellery is permitted, including but not limited to ear rings, necklaces, bracelets or piercings of any kind. Wedding rings/bands are permitted. * No form fitting clothing (including yoga pants, muscle shirts) or revealing clothes (including see-through clothes that show underwear/lingerie, short shorts, short skirts) are permitted. * Healthcare providers are expected to wear their typical uniform (ex. scrubs). All other volunteers/staff must wear the program t-shirt/uniform during program hours/sessions. * All staff and volunteers must use their best judgment to respect Christian principles of simplicity, modesty and professionalism in their attire. * Violations of the dress code will lead to a warning followed by dismissal for repeat violations.

Yes

Respect and integrity *

I agree to treat all staff, volunteers and especially patients/guests with Christlike kindness, modesty and respect. I understand that any acts of harrassment or improriety, whether verbal, physical or sexual, will lead to immediate dismissal from the program.

Yes

Faithfulness, leadership and patient care *

I agree to respect program leadership from Paradise Fields and Lifestyle Is Medicine, my department leader and serve with faithfulness in my assigned role. I understand that this is a clinical program and as such, that the medical and naturopathic doctors have ultimate responsibility for the care of patients/guests. I will therefore respect their directions with respect to the care of patients/guests nor contradict the information they share with patients/guests.

Yes

Medical advice and health topics *

As a non-clinical team member, I understand that I am not authorized to share medical advice and agree not to share medical advice to patients/guests. I agree to refrain from sharing health information that contradicts those provided by the healthcare team and will refer any health-related questions to the appropriate healthcare provider (e.g. medical question to the doctors, nutrition questions to the nutritionist etc). I will refrain from discussing controversial health topics with patients/guests.

Yes

Patient info confidentiality *

Patient records and information are strictly confidential. I agree to never discuss any patient's health information with others except for with staff health care providers within the clinical setting of the immersion.

Yes

Safety and Feedback *

I understand that as a valued member of the team, I am entitled to be treated with respect by all staff and leadership and provided a safe environment to serve. I understand that I will be provided with a complaints/feedback mechanism to voice concerns and feedback.

Yes

Photos and videos *

I understand that photos and videos will be taken during public components of the program and that I may appear in such photos/videos. I agree to appear in such photos/videos and permit Paradise Fields, Lifestyle Is Medicine, Not By Bread Alone and other program partners to share such photos/video publicly, including on websites and social media, and in the production of other multimedia content (e.g. promotional video) and for future marketing.

Yes

I understand that my agreement with the statements above is binding over the full duration of the program. I understand that violations of any of the clauses above will lead to dismissal. * *

Yes

Release and indemnity *

WHEREAS the organizers, Lifestyle Is Medicine and Paradise Fields, provides opportunities for individuals to participate in doing evangelistic health work; AND WHEREAS I am participating on a voluntary basis; AND WHEREAS the lifestyle medicine program that I am volunteering for as selected above is provided under the auspices of Lifestyle Medicine and Paradise Fields; And WHEREAS Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and its program partners wish to expressly disclaim any liability for any and all damages with respect to any volunteer up to and including personal injury or death; NOW THEREFORE in consideration of the agreements herein contained and for the purpose of inducing Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and all other program partners to arrange and facilitate and permit such health work, I HEREBY AGREE: A. to release, hold harmless and indemnify Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and all other program partners and their respective heirs, successors, assigns, officers and employees against any liability arising in any manner whatsoever up to and including personal injury and death and incurred by me by reason of having undertaken such travel and/or work; B. to release, hold harmless and indemnify Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and all other program partners and their respective heirs, successors, assigns, officers and employees, for any personal injury or death to any minor person permitted to volunteer by me; C. that Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and all other program partners and their respective heirs, successors, assigns, officers and employees, shall not be liable for and is expressly released from liability or damage caused to the personal property of mine including personal injury or death whether caused by the gross negligence of Lifestyle Is Medicine or otherwise; D. and to undertake any risks associated with participation in lifestyle medicine immersion programs under the auspices of Lifestyle Is Medicine and waives any remedy or entitlement on account of the same against Lifestyle Is Medicine, Paradise Fields, Pathways Lifestyle Medicine Clinics, Not By Bread Alone, Marcos Made, God Inspired, and all other program partners and their respective heirs, successors, assigns, officers and employees.

Yes