Individual Volunteer Waiver
Waiver of Liability for Diaper Bank of NC Volunteers.
At which branch of the Diaper Bank of NC will you be volunteering?
Triangle Branch located in Hillsborough (Serves Durham, Wake, Orange, Alamance, Granville, Harnett, Cumberland, Hoke, Moore Counties)
Greater Charlotte Branch located in Charlotte (Serves Mecklenburg and Cabbarus Counties)
Greater Triad Branch located in Winston-Salem (Serves Forsyth, Guilford, Davidson, Stokes, Surry, Yadkin, Randolph Counties)
Lower Cape Fear Branch located in Wilmington (Serves New Hanover, Brunswick, Pender, Duplin, Bladen, and Columbus Counties)
Are you volunteering as a member of a school, church, service, or civic organization? Leave blank if you are not affiliated with any group.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Would you like to join our mailing list? (2-4 mailings per year)
Yes
No
In the event of an emergency, the following person should be called.
*
Emergency Contact Phone Number
*
If you are volunteering with minor children, please list their names and ages below.
The above listed minor children have my permission to participate in this Diaper Bank of North Carolina event. Digital Signature of Parent/Guardian (Please type your full legal name)
I shall at all times indemnify, defend, and save the Diaper Bank of North Carolina (DBNC) and its agents harmless from, any and all damages, losses, claims, including claims and actions relating to injury to or death of any person or damage to property, demands, suits, recoveries, costs, and expenses, court costs, attorney fees, and all other obligations by or to third parties, arising out of or resulting from participation in the DBNC aforementioned activity, except in cases of gross negligence or intentional wrongdoing by the DBNC or its agents.
*
Yes
I agree that the Diaper Bank of North Carolina (DBNC) may take photographs of myself or my child and use these images to promote the purposes of the DBNC with no compensation due to me. The DBNC will NOT use full names or identify individuals in pictures.
*
Yes
I have disclosed any pertinent information regarding any criminal background, and understand fully the Diaper Bank of North Carolina has a zero tolerance policy for drugs, alcohol, sexual harassment, criminal activity and unprofessional communication while you are associated with the organization.
*
Yes
Volunteers may be asked to carry heavy items, work in areas with low vertical clearance, operate vehicles, and perform other tasks that can be considered dangerous, therefore, volunteers are required to follow the instructions of Diaper Bank of North Carolina board, staff, and interns at all times.
*
Yes
By digitally signing this form, I verify that I understand that I am exposing myself or my child to accident, injury, death, and property damage through volunteering with the Diaper Bank of North Carolina.
*
Yes
Signature (Please type your full legal name)
*
Date
*
-
Month
-
Day
Year
Date
Submit
I accept full responsibility that, in volunteering, I risk being exposed to and possibly contracting coronavirus (COVID-19) or other potentially fatal or non-fatal illnesses. I realize that this risk is not only to myself, but that I may unintentionally spread the virus or illness to others.
*
Yes
I agree to follow the safety rules and instructions while engaged in my volunteer activities with Diaper Bank of NC and that, after volunteering, I shall follow recommended health practices, including hand washing, cleansing of hard surfaces, social distancing, avoiding contact with sick and elderly persons without using appropriate PPE (please see CDC and NCDHHS for up to date current recommendations) In doing so, I knowingly do so at my own risk and risk to others.
*
Yes
I understand that while masks are not required to volunteer at DBNC, they are encouraged.
*
Yes
I agree that if I am exhibiting, or have exhibited any COVID-19 symptoms such as a fever, persistent cough, etc. in the past 3 days, that I will stay at home and get tested, if possible, to avoid infecting others.
*
Yes
If I become ill up to 2 weeks after my volunteer shift at Diaper Bank of NC, I will let the Diaper Bank staff know.
*
Yes
On behalf of myself, my heirs, assigns and representatives, I hereby release, waive, discharge, and hold harmless Diaper Bank of NC and its respective officers, directors, agents, volunteers, and employees from any and all liability, claims, demands, damages, fees or expenses, or actions whatsoever arising out of or related to any loss, damage, illness, or injury, including death, that may be sustained by me as a result of my participation as a volunteer at Diaper Bank of NC.
*
Yes
By accepting and submitting this form, I acknowledge the seriousness of the health risks involved, and knowingly consent to accept the risk and abide by the safety pledge.
*
Yes
Digital Signature (Please type your full legal name)
Today's Date
*
Name
*
First Name
Last Name
Email
*
example@example.com
If under 18, I confirm that this addendum was read and approved by a parent or guardian. (If over 18 click NA).
*
Yes
NA
*
Signature and contact information of Parent or Legal Guardian (If over 18 put NA)
Should be Empty: