I have been formally instructed regarding the agency’s policies and procedures for maintaining the confidentiality of all information contained in client and personnel files and records, as well as any other proprietary information regarding the agency that may be obtained verbally or otherwise.

Such information may not be disclosed or used by anyone outside or within the agency unless expressly authorized by the agency’s executive director and/or designee.

I understand that any breach of confidentiality may be grounds for immediate termination of employment.

The following questions are designed to assist Governing Body members, Professional Advisory members and staff in determining the nature and extent of any outside interest that might possibly involve conflict of interest with the affairs of the organization. Please read each question carefully and then answer briefly and concisely in the space that follows. In the event that you have any doubts as to what the question means, answer it to the best of your ability and identify the reason for doubt.

• Competitor: A person offering for sale or selling products and/or services in competition with this organization.
• Family: Spouse, parents, children, brothers, sisters.
• Purchaser: Any person who buys, rents, or otherwise procures, has bought, rented or procured, or in any way has received from this organization any goods, materials, wares, merchandise, supplies, machinery, equipment, or professional and/or other service.
• Person: An individual, firm, partnership, trust. corporation, or other business entity.
• Vendor: Any person who sells, rents, agrees 10 furnish, has offered to sell, rent, or agree to furnish, or has sold supplies, machinery, equipment, real estate, credit, insurance, or service, profession or otherwise, to or on behalf of the organization.

3. Related Staff Members:

A. - Are any present staff members of this organization related to you either by blood or other legal family relationships?

I certify that the above questions have been answered to the best of my ability, and of my own free will, and in the interest of cooperating with the agency. I also agree that if at any future time I should become aware of any conflict arising, that is not mentioned herein, I shall contact the Governing Body.

I hereby certify that I have read and fully understand the contents of the Employee Handbook. Furthermore, I have been given the opportunity to discuss any information contained therein or any concerns that | may have. I certify that my employment and continued employment is based in part upon my willingness to abide by and follow the Agency's policies, rules, regulations and procedures. My signature below certifies my knowledge, acceptance and adherence to the Agency's policies, rules, regulations and procedures and that the Agency's offer of employment was based on my promise to abide by and follow said policies, rules, regulations and procedures.

I further certify that my application and subsequent acceptance of employment is true and bona fide, and I am honestly interested in working in the position(s) for which I have been employed. Furthermore, I certify that I have sought and obtained employment with this Agency solely to provide me with the benefits of a job and for no other purpose.

1 acknowledge that the Agency reserves the right to modify or amend its policies at any time, without prior notice. These policies do not create any promises or contractual obligations. between this Agency and its employees. At this Agency, my employment is at will. This means I am free to terminate my employment at any time, for any reason, with or without cause, and this Agency retains the same rights. I further understand and agree that the Owner/President of this Agency is the only person who may make an exception to this, including the at-will status of my employment, and it must be in writing and duly executed by the Owner/President of this Agency.

If applicable to my employment, I have read and understood the notice regarding polygraph tests and my rights under this state's law.

AUTHORIZATION TO RELEASE INFORMATION: 1 authorize the references and/or employers listed on my employment application, or any other documents I have provided to this Agency, to give the Agency any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing such information to this Agency. I agree and understand that this Agency and its agents may investigate or seek information concerning my background and/or previous employment, whether of record or not. I further agree and understand that if employed, the Agency may at any time seek any information from whatever source, which in its discretion, it deems relevant to my employment. I also understand that any investigation or information sought regarding my previous employment or consumer records may not be completed or in possession of this Agency and thus my continued employment may be affected by such information once received. | hereby acknowledge, confirm, convey, agree and grant this Agency's right to act on any additional information received including, at the Agency's sole discretion, termination of my employment.

NO DRUG USE POLICY: This Agency does not hire persons who use illegal drugs. All persons seeking employment or employed with this Agency may be required to take and pass a screen for illegal drugs, and may be subject to periodic tests for illegal drugs. I hereby voluntarily consent to provide a urine specimen (or blood specimen as required for alcohol testing only) at a collection facility designated by this Agency, and further consent to have the specimen tested at a laboratory selected by this Agency. I hereby certify that

I understand that the agency staff may use electronic signatures on all computer- generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.

For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge the combined use of my Electronic Signature Passcode and Log In authentication password will serve as my legal signature. I understand that I will be required to update my password regularly for security purposes. I understand that prior to exporting documentation to the agency server, 1 am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into my organization's Well Sky application, and as such, I will

• Not share or otherwise compromise my electronic signature credentials (Log In authentication password or Electronic Signature Passcode)
• Exit the online application at the end of each working day or whenever the computer is not in my immediate possession.
• Not save my Log In password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application.
• Review all of my documentation online prior to submitting to the agency server

Attach a voided check for bank accounts to which funds should be deposited (if necessary)

is hereby authorized to directly deposit my pay to the account(s) listed above. This authorization will remain in effect until I modify or cancel it in writing.

in accepting employment with the Agency accept and understand the first 90 days of employment will be considered my introductory period. If for any reason my employment is terminated during this period, I understand and accept this account will not be charged with any unemployment benefits I may be eligible to receive under the State Unemployment Compensation Law.

I also understand and accept that at the end of the 90-day period, I will receive a written evaluation of my work performance. Should the Agency fail to provide this written evaluation, it shall be understood and accepted by all involved that the introductory period will have been completed satisfactorily.