I hereby state that I will abide by all the rules of Good Samaritan Health Services. I certify that all statements in this form are true and correct, to the best of my knowledge. I agree to treat all information received about patients as confidential. I understand that failure to do so may result in termination of my volunteer services with Good Samaritan Health Services. I authorize Good Samaritan Health Services to verify any information necessary pertaining to my volunteer application and authorize each employer and any local, state or federal law enforcement agency, or any reference named, to confidentially provide any pertinent information which may be requested. I authorize Good Samaritan Health Services to use photographs or videos and quotes from me for promotional purposes in any type of media, including its website. The photographs, videos or quotes may not be used for profit without my express permission. I understand that I will not be paid or rewarded for providing this authorization.