Consent to ONLINE Classes

Information, Authorization, and Consent to Use Online Classes
  • This document indicates your consent to participate in distance-oriented classes, which take place over a telehealth platform, Zoom.

    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. I fully understand that CSCVVSB and program partners recommend that anyone participating in any exercise program check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any exercise program could result in injury or illness.

    CSCVVSB asks 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. By completing and submitting this consent electronically, you are agreeing to abide by our policies for the confidentiality, comfort and safety of our members.

    By completing and submitting this consent electronically, I agree to release, waive, discharge and hold harmless CSCVVSB and its program partners, affiliates, employees, 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.

    By completing and submitting this consent electronically, I hereby indicate my compliance with the above stated telehealth platform Zoom experience and reserve the right to revoke my consent, in writing, at any time.

    By completing and submitting this consent electronically below, you are indicating that you have read and understand the contents of this form, you agree to these policies, and you are authorizing your clinician/instructor to utilize the online platform, Zoom, method above.
  • Date Format: MM slash DD slash YYYY
  • If you need help completing this form or have any questions, please contact us at programs@cancersupportvvsb.org.