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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 1, Chapter 6: Manual Exhibit 1-6-6F

Sample Letter of Authorization to Serve as a Volunteer

Dear:

Having met the requirements for serving under the volunteer service program of the_________(name of organization)_________, you are hereby authorized to serve without compensation as a volunteer at _________(name and location of health care facility)____________.  Your acceptance of the opportunity to serve on such a basis means that you waive all claim to pay for services rendered.
(Include paragraph about arrangements, as appropriate)

Your interest in the health needs of the people we serve is deeply appreciated, and we are grateful for the assistance you are willing to provide in meeting these needs.

Please sign the enclosed copy of this letter in the space provided below and return it to us in the enclosed envelope.
Sincerely yours,
(Signature)
(Name and title of official authorized to accept volunteer service.)

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I accept the opportunity to provide volunteer service as offered above and agree to the conditions stated.  I understand that this agreement may be terminated at any time either by me or an official of the Department of Health, Education, and Welfare.

__________________________________________________________________
Signature

________________________________________
Date


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