ROPE HOLDER VOLUNTEER APPLICATION

Thank you for your interest in volunteering for Hadassah's Hope. Please complete this for and select all areas that interest you.

Existing Volunteers: Please complete the form for the role(s) which you are currently assigned.

Please select one or more of the options below. These are the teams which interest you and/or your existing assigned team.

Name

First Name Last Name

How did you hear about Hadassah's Hope?

First 5 digits of your Social Security Number (FOR OUTREACH AND ROPE HOLDER APPLICATION BACKGROUND CHECKS) *

Birthday

Date

Club Name

General Role (Team Lead, Volunteer, etc.)

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Phone Number

Area Code Phone Number

Primary Phone Number Type

Secondary Phone Number

Area Code Phone Number

Secondary Phone Number Type

Email

example@example.com

Emergency Phone Contact Information (name, phone)

Additional notes may be added to provide critical information as needed.

T-Shirt Size (S, M, L, XL, XXL)

Form Revision 07/2020

NAME OF PARTICIPANT:

DISCLOSURE: THIS IS FULL RELEASE OF POTENTIAL CLAIMS TO BE COMPLETED BY THE VOLUNTEER. THIS FORM MUST BE SIGNED AND THE ORIGINAL RECEIVED BY HADASSAH’S HOPE PRIOR TO VOLUNTEERING.

HADASSHA’S HOPE IS COMMITTED TO CONDUCTING ITS ACTIVITIES IN THE SAFEST MANNER POSSIBLE AND HOLDS THE SAFETY OF ITS VOLUNTEERS IN THE HIGHEST REGARD. WE CONTINUALLY STRIVE TO REDUCE THE RISK OF INJURY AND INSIST THAT ALL VOLUNTEERS FOLLOW SAFETY RULES AND INSTRUCTIONS THAT HAVE BEEN DESIGNED TO PROTECT THEIR SAFETY.

IN THE EVENT OF AN ACCIDENT INVOLVING AN INJURY, PLEASE REPORT IT PROMPTLY TO THE STAFF OR OUTREACH LEAD. I UNDERSTAND AND ACKNOWLEDGE THAT HADASSAH'S HOPE DOES NOT CARRY ANY INSURANCE, AND I ACKNOWLEDGE THAT HADASSAH'S HOPE HAS ADVISED ME THAT HADASSAH'S HOPE DOES NOT ACCEPT ANY RESPONSIBILITY FOR ANY INJURY, LOSS OR DAMAGE TO MY PERSON. I FURTHER ACKNOWLEDGE THAT HADASSAH'S HOPE HAS RECOMMENDED THAT I CARRY OR OBTAIN PRIMARY MEDICAL INSURANCE TO COVER POSSIBLE MEDICAL NEEDS.

AS A VOLUNTEER, I RECOGNIZE THAT THERE ARE CERTAIN RISKS OF PHYSICAL INJURY AND AGREE TO ASSUME SUCH RISK AND ANY DAMAGE OR LOSS I MAY SUSTAIN AS A RESULT OF VOLUNTEERING FOR ANY AND ALL ACTIVITIES ASSOCIATED WITH HADASSAH’S HOPE. I FURTHER AGREE TO WAIVE AND RELEASE ALL CLAIMS I MAY HAVE AS A RESULT OF VOLUNTEERING AGAINST HADASSAH’S HOPE AND ITS OFFICERS, AGENTS, SERVANTS, EMPLOYEES, AND OTHER VOLUNTEERS WITH WHOM I MAY BE WORKING.

IN THE EVENT OF AN EMERGENCY, I AUTHORIZE OFFICIALS OF HADASSAH’S HOPE TO SECURE FROM ANY LICENSED HOSPITAL, PHYSICIAN, AND/OR MEDICAL PERSONNEL ANY TREATMENT DEEMED NECESSARY FOR MY IMMEDIATE CARE AND AGREE THAT I WILL BE RESPONSIBLE FOR PAYMENT OF ANY AND ALL MEDICAL SERVICES.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE WARNINGS OF RISK, PERMISSION TO SECURE EMERGENCY TREATMENT AND WAIVER AND RELEASE OF ALL CLAIMS AGAINST HADASSAH’S HOPE.

I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS HADASSAH’S HOPE AND ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FROM ANY AND ALL CLAIMS RESULTING FROM INJURIES, DAMAGES AND LOSSES SUSTAINED BY ME OR ARISING OUT OF, CONNECTED WITH, OR IN ANY WAY ASSOCIATED WITH THE ACTIVITIES OF HADASSAH'S HOPE.

THE VOLUNTEER DOES HEREBY GRANT AND CONVEY UNTO HADASSAH’S HOPE ALL RIGHT, TITLE AND INTEREST IN ANY AND ALL PHOTOGRAPHIC IMAGES AND VIDEO OR AUDIO RECORDINGS MADE BY HADASSAH'S HOPE DURING THE VOLUNTEER’S WORK FOR HADASSAH'S HOPE, INCLUDING, BUT NOT LIMITED TO, ANY ROYALTIES, PROCEEDS, OR OTHER BENEFITS DERIVED FROM SUCH PHOTOGRAPHS OR RECORDINGS.

IN CONSIDERATION OF MY BEING ACCEPTED BY HADASSAH'S HOPE FOR PARTICIPATION IN OUTREACH, I MAKE THE REPRESENTATIONS AND UNDERTAKINGS SET OUT BELOW:

IN CONSIDERATION OF MY BEING PERMITTED TO PARTICIPATE AS A MEMBER OF A HADASSAH'S HOPE OUTREACH AS MENTIONED ABOVE: (PLEASE INITIAL EACH PARAGRAPH)

I ACCEPT AND ASSUME ALL RISKS AND HAZARDS FROM THIS ACTIVITY, BOTH KNOWN AND UNKNOWN, INCLUDING BUT NOT LIMITED TO THE RISKS AND HAZARDS IDENTIFIED ABOVE.

Initials:

I HEREBY VOLUNTARILY RELEASE, FOREVER DISCHARGE, AND AGREE TO HOLD

HARMLESS AND INDEMNIFY Hadassah's Hope, ITS DIRECTORS, OFFICERS, AGENTS,

EMPLOYEES, COORDINATORS, FACILITATORS, VOLUNTEERS, AND OTHER TEAM MEMBERS FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, ACTIONS OR RIGHTS OF ACTIONS, WHICH ARE RELATED TO, ARISE OUT OF, OR ARE IN ANY WAY CONNECTED WITH MY PARTICIPATION IN THIS ACTIVITY, WHICH I NOW HAVE OR MAY HAVE IN THE FUTURE, SPECIFICALLY INCLUDING BUT NOT LIMITED TO THE NEGLIGENT ACTS OR OMISSIONS OF ANY PERSON SO RELEASED, HELD HARMLESS AND INDEMNIFIED, AND SPECIFICALLY INCLUDING CLAIMS RELATING TO ANY PERSONAL INJURY THAT I MAY SUFFER, WITH EXCEPTION TO GROSS NEGLIGENCE.

Initials:

I AGREE THAT I WILL NOT MAKE A CLAIM, FILE SUIT OR DEMAND ANYTHING FOR ANY INJURY, DEATH OR LOSS THAT ARISES FROM MY PARTICIPATION IN THIS ACTIVITY.

Initials:

I AGREE TO PAY THE COSTS AND/OR LEGAL EXPENSES INCURRED BY THE STAFF, ORGANIZERS AND/OR PARTICIPANTS AS A RESULT OF ANY CLAIM OR SUIT FILED BY ME, OR FILED BY ANYONE ELSE AS A RESULT OF MY CONDUCT.

Initials:

I CONSENT AND AGREE TO PAY FOR ANY MEDICAL TREATMENT RENDERED TO ME BY ANYONE FOR ANY INJURY OR OTHER MEDICAL SITUATION DURING, OR RESULTING FROM MY PARTICIPATION.

Initials:

I AGREE THAT THESE PROMISES, AGREEMENTS, ASSUMPTIONS OF RISK AND RELEASES BIND ME, MY FAMILY, AND MY HEIRS OR LEGAL REPRESENTATIVES AND ASSIGNS.

Initials:

I HAVE READ THIS RELEASE CAREFULLY, INCLUDING THIS PAGE AND THE PRIOR PAGES. I AM FULLY AWARE THAT I AM WAIVING IMPORTANT LEGAL RIGHTS AND SIGN OF MY OWN FREE WILL.

PRINT NAME:

Signature

Clear

DATE:

Date

ADDRESS:

TELEPHONE:

EMERGENCY CONTACT:

TELEPHONE:

IF YOU ARE UNDER THE AGE OF 18, YOUR PARENT/GUARDIAN MUST READ AND SIGN THIS FORM.

PARENT/GUARDIAN SIGNATURE:

DATE

Date

ADDRESS:

TELEPHONE:

In Consideration of being allowed to participate in any way in Hadassah’s Hope Ministry and Outreach activities and events, the undersigned acknowledges, appreciates and agrees that:

1. The risks of illness (ex: communicable diseases such as MRSA, influenza, and COVID-19) from the activities involved in this ministry are significant, including potential sickness and in some instances death. Access to others where medical status is unknown presents possible risks. Even with using cautionary measures such as masks, gloves, handwashing and alcohol-based wipes and liquids, the risks of serious illness may exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES of others, and assume full responsibility for my participation;

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard or behaviors during my presence or participation, I will remove myself from participation and bring such to the attention of the Outreach Team Leader, assigned Rope Holder, and others as deemed appropriate; and,

4. I, for myself and on behalf of my heirs, assigned personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Hadassah’s Hope Inc., the CEO, the Board of Directors, agents, representatives and/or employees, other volunteers and/or participants, sponsoring churches, sponsoring businesses, advertisers and any/all third party individuals involved in and/or supporting the ministry, club owners, club employees, any/all third party individuals supporting visited clubs or other locations, and if applicable, owners and lessors of premises used to conduct the event (“RELEASES”), WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WITHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Participant Name (Printed):

Participant Name (Signed):

Date Signed:

Date

Emergency Phone Number:

HH ROPE HOLDER APPLICATION

VOLUNTEER LIABILITY RELEASE FORM

PARTICIPANT INFORMATION

LIABILITY RELEASE

MEDICAL RELEASE

INDEMNIFICATION

PHOTOGRAPHIC RELEASE

REPRESENTATIONS

Hadassah’s Hope Outreach Club Visit Waiver and Release of Liability

READ BEFORE SIGNING