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8. Electronic Signature Agreement*

   By checking the "I agree" box below, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

   1. I agree.
10. I pledge to prevent abuse, neglect, or harm toward any person with special needs, consistent with agency policy. In addition, to the extent I am required to report abuse, neglect, or harm of any person with special needs by law, rule, or regulation, I agree to abide by the law, rule, or regulation. If I learn of, or witness, any incident of abuse, neglect or harm toward any person with special needs, I will offer immediate assistance, notify emergency personnel, including 9-1-1, and inform the management of this organization, consistent with agency policy. I acknowledge that I have read and that I understand the Code of Conduct.
12. First Name*
13. Last Name*
15. Electronic Signature*
16. Date*
    Date
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18. 1. Receive an email copy of this form.
19. Email address

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