April 16 Carnegie Clean Up Day Volunteer Form

Name

First NameLast Name

Date

Age if under 18 (Volunteers must be at least 15 years old)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Do you or your child have special needs?

Parental consent required for volunteers under 18. (Volunteers must be 15 years or older)

My child has my consent to participate in this clean up event.

Emergency Contact

Emergency Contact Phone Number

VOLUNTEER WAIVER - I understand that I will be spending the day as a volunteer and will participate at my own risk. I acknowledge that my participation is voluntary and does not constitute a condition or requirement of employment. I further acknowledge that the Project will occur throughout the Borough of Carnegie. I attest that I am physically fit and prepared for this event. I will not create an unsafe situation for other individuals or myself nor will I engage in any task with which I am not completely comfortable. I will abide by all applicable federal, state and local laws, as well as the rules and directions of the sponsors and coordinators. If I see any situation that I feel is unsafe, I will immediately call it to the attention of an event organizer. If I bring any children or young adults with me to participate in the Project, I will be solely responsible for providing for their safety and will keeping them under close supervision at all times. FOR EACH PARTICIPANT UNDER 18, THE PARENT OR GUARDIAN MUST FILL OUT A SEPARATE WAIVER. On behalf of myself, as well as my heirs, executors, administrators and assigns, I hereby forever release, discharge, waive and agree to indemnify and hold harmless The Borough of Carnegie, Carnegie Community Development Corporation and Adventist Community Services of Greater Pittsburgh along with their respective officers, directors, agents, employees, contractors, successors and assigns, and any volunteers from and against any and all claims, demands, actions, causes of action, obligations, liabilities, suits, losses, damages, costs, expenses, and fees, including, without limitation, court costs and attorneys’ fees, of any and every nature of character, including, without limitation, for death, personal injury and/or loss of property, whether anticipated or unanticipated, directly or indirectly arising out of or connected in any way with my participation in the Project. Finally, I hereby grant The Borough of Carnegie, Allegheny CleanWays, and Keep PA Beautiful the full and complete permission to use in legitimate promotions of the Project photographs of me and quotations from me.

I have read and understand the volunteer waiver.

Signature

Clear

Parent Signature if Volunteer is under 18. (Volunteers must be at least 15 years old)

Clear

Please verify that you are human*