After-School All-Stars Hawaii Youth Volunteer Application

YOUTH VOLUNTEER APPLICATION
CONTACT INFORMATION
Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you presently attending High School?

Yes No
If yes, name of High School:
If yes, please provide the name and phone number of one of your High School teachers who can provide a reference for you?
Teacher Name
Teacher Phone Number
Did you take part in an ASAS program in Middle/Intermediate school?

Yes No
If yes, what school and when?
I confirm that I am under 18:

Yes No
When will you be 18?

Month Day Year
Date/Year
Important Note: Because ASAS work in conjunction with the Department of Education, all adult volunteers will be required to undergo a State and Federal background check. All volunteers who are under 18 will be required to undergo a State and Federal background check when they reach the age of 18. At that time, ASAS will provide instructions and will pay for said backgrounds checks.
PERSON TO CONTACT IN THE CASE OF AN EMERGENCY
Name
Relationship
Cell Phone
MEDICAL INFORMATION
List any medical problems/conditions
Allergic to any medications?

Yes No
Please List:
Dietary Restrictions/Allergies:

Yes No
Please List:
PARENT LIABILITY/PARENT AUTHORIZATION
In consideration of my minor/ward being allowed to volunteer at the After-School All-Stars (ASAS) Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND ASSUME FULL

RESPONISIBLITY FOR MY CHILD'S VOLUNTEERISM; and, 2. I willingly agree to comply with the program's stated and customary terms and conditions for my child's volunteering. If however, I observe any unusual significant concern in my child's readiness for volunteering and/or in the program itself, I will remove my child from volunteering and bring such to the attention of the nearest official immediately; and, 3. I, for myself and of behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMIFY AND HOLD HARMLESS ASAS, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners, and leasers of premises used for the activity ("RELEASEES"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEEES OR OTHERWISE, to the fullest extent per-mitted by law.

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

Clear
Date

Month Day Year
CONSENT FOR TREATMENT
I understand that in case of emergencies, ASAS will make every effort to contact the parent(s)/guardian(s) before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by ASAS to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I (the parent/guardian) will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold the ASAS their officers, officials, agents and/or employees, harmless there from.
Parent Signature

Clear
Date

Month Day Year
AGREEMENT AND SIGNATURE
By submitting this volunteer application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal.

I agree, that if I am selected to be a volunteer at After-School All-Stars Hawaii, I will volunteer for at least 20 hours per quarter, said hours will be at the convenience of the program.
Applicant Signature

Clear
Date

Month Day Year
Parent Signature

Clear
Date

Month Day Year
Should be Empty:

YOUTH VOLUNTEER APPLICATION

CONTACT INFORMATION

PERSON TO CONTACT IN THE CASE OF AN EMERGENCY

MEDICAL INFORMATION

PARENT LIABILITY/PARENT AUTHORIZATION

CONSENT FOR TREATMENT

AGREEMENT AND SIGNATURE