Ambassador Patient Forms

Patients who wish to utilize the Ambassador Program must electronically sign the Patient Contract and Patient Accident Waiver/Release of Liability before participating in the Ambassador Program. Click below to expand, read and sign the forms. Click submit to send the form to the A Breath of Hope office. Please complete both forms. You will be contacted after submitting the forms.

Patient Contract - Volunteer Driver Program

Volunteer Driver Program – Patient Contract

Welcome to the Ambassador Volunteer Driver Program (VDP). We are happy to assist with your medical and support group transportation needs. In order to best serve you, we ask that you please adhere to the following procedures and expectations:

Program Requirements. In order to be eligible for our Volunteer Driver Program, clients MUST:

  • Be a lung cancer patient at a partner hospital.
  • Be ambulatory. (the use of cane or walker is acceptable, but volunteer drivers cannot assist clients using wheelchairs)
  • Wear a seatbelt at all times when seated in the volunteer driver’s car.
  • Use this driving program for medical appointments (may include Pharmacy pick up or partner support groups).
  • Be on time for selected pickup time.
  • Contact the ABOHLF cell (952-456-2845) if a volunteer has not arrived for a scheduled ride before making alternate plans.
  • Inform the Ambassador Coordinator of any cancellations or changes at least two days before the appointment. To ensure a successful program, please minimize cancellations.
  • Understand that three non-emergency related cancellations will result in a three-month probationary period in which we will not be able to provide volunteer driver services to you.
  • Understand that our volunteer driving program is a supplemental service available to patients following a lung cancer diagnosis for treatment and support groups. (based on driver availability and subject of change) Patients may receive up to ten rides annually. Contact the ABOHLF office to request extended services or assistance in seeking alternative transportation services if needs are long term.

Scheduling Procedures: To place a ride request, please call the service request line at 952-456-2845, a staff member will return your call within 24 business hours. When making a ride request, please have the following information available:

  • Your name and address
  • Name and address of medical facility
  • Doctor’s name
  • Date and time of appointment
  • Requested pick up time
  • Expected length of appointment

Ride requests made three to five days in advance of their medical appointments are more likely to be accommodated. This is to allow adequate time to coordinate a volunteer driver for your ride.

Patients must share with the coordinator information necessary to complete the Patient Support Request.

Due to the voluntary nature of our program, ride fulfillment is not guaranteed at the time of scheduling.

Patients will receive a confirmation call from ABOHLF staff when a volunteer driver is found for the request. Please do not assume you have a ride until the Ambassador Coordinator confirms. If a volunteer driver cannot be found for a requested ride, the Ambassador coordinator will notify you within 24-hour notice prior to the scheduled appointment.

Volunteer drivers will make a confirmation call the day before a ride.


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Patient Accident Waiver / Release of Liability

PATIENT ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH RECEIVING CAR RIDES AND MENTORING FROM A Breath of Hope Volunteer Ambassadors, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the DRIVERS/persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

I certify that there are no health-related reasons or problems which preclude my ACCEPTING RIDES OR MENTORING FROM A Breath of Hope Volunteer Ambassadors. I acknowledge that this Accident Waiver and Release of Liability Form will be used by a Breath of Hope Lung Foundation (ABOHLF), its volunteers, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.

In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: The A Breath of Hope Lung Foundation, (ABOHLF) and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I acknowledge that ABOHLF and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.


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