Confidentiality & Member Safety Agreement

  • Our staff and volunteers respect the privacy of our members. Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.

    We ask that our members respect each other’s privacy and do not disclose the identity of others who participate at CSCVVSB, or what is said in a support group or program. However, we are not able to ensure confidentiality of all members, as we would have no way to enforce it. Please read and sign below regarding our policies for the confidentiality, virtual (online) confidentiality and communication, comfort and safety of our members.
    • I understand that the CSCVVSB staff and volunteers will be respectful of my privacy but cannot ensure the confidentiality adherence of other members.
    • I understand that the CSCVVSB reserves the right, at its sole discretion, to refuse or discontinue the use of its facilities and its virtual (online) platforms to any person.
    • I agree not to share other members’ personal information, such as name, address, email address, phone number, and medical information, to any other third party.
    • I understand that the CSCVVSB does not provide medical advice or assistance of any kind.
    • I agree not to attend the CSCVVSB programs if I have a communicable illness, as some of our members have compromised immune systems.
    • I understand that the CSCVVSB is a fragrance-free space, as some members may be very sensitive to smell.
    In consideration of my acceptance as a member of Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB), and its partners (including, but not limited to: Saint John’s Dignity Health, Ventura County Medical Center) and the use of the facilities and services provided without charge, I agree that I will not take any legal action against the CSCVVSB, its program partners, its officers, agents, employees, interns, or any other participant or support person at CSCVVSB, based in any way on what is said or done by such officers, agents, employees and participants at CSCVVSB in a good faith effort to provide those services and facilities.

    HEALTH LIFESTYLE/MIND-BODY PROGRAM ATTENDANCE: I fully understand that CSCVVSB and program partners recommend that anyone participating in any exercise/relaxation/social program, both in-person and virtual (online), check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any such program, both in-person and virtual (online), could result in injury or illness.

    By signing this document, I agree to release, waive, discharge and hold harmless CSCVVSB and its program partners, affiliates, employees, interns, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in the exercise program.

    I have read and understand the waiver and release agreement.
  • MM slash DD slash YYYY
  • Thank you! We look forward to having you as a member of our community.

    If you need help completing this form or have any questions, please contact us at