Volunteer Application

VOLUNTEER APPLICATION

ANY VOLUNTEER MUST COMPLETE THE FOLLOWING VOLUNTEER RELEASE FORM BEFORE YOU MAY BEGIN YOUR ACTIVITIES IN OR ABOUT THE PREMISES OR ANY OTHER OFFSITE LOCATION.

Agency Name

Agency Address

Street Address

Street Address Line 2

CityState

Zip Code

Contact's Name*

First NameLast Name

Contact's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact's Phone Number*

Area CodePhone Number

Contact's E-mail*

RELEASE

I acknowledge there are certain inherent risks serving as a volunteer, including but not limited to physical injury and death. I acknowledge that all risks can not be prevented and I assume those risks beyond the control of JACOB'S BRIDGE TO LEARNING, INC faculty and staff. I represent that I am physically able, with or without accommodation, to participate in volunteer service, and that I am able to use the equipment and/or supplies described.

Should I require emergency medical treatment as a result of accident or illness arising during volunteer work, I consent to such treatment. I acknowledge that JACOB'S BRIDGE TO LEARNING, INC does not provide health and accident insurance for volunteers and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment. I will notify JACOB'S BRIDGE TO LEARNING, INC staff at my volunteer site in writing if I have medical conditions about which emergency medical personnel should be informed.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE RELEASE/WAIVER AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS WAIVER VOLUNTARILY.

Volunteer Name

First NameLast Name

Volunteer eSignature

Date

If participant is under age 18, parent or guardian signature is required:

Parent/Guardian Name

First NameLast Name

Parent/Guardian eSignature