MCCA Volunteer Sign Up Form

Volunteer Name*

First NameLast Name

Volunteer E-mail*

Volunteer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Volunteer Phone Number*

Area CodePhone Number

Are you over 18?*

YesNo

I have already connected with the Housing Navigation Coordinator for volunteering.*

YesNo

Are you volunteering as an individual or group?*

IndividualGroup

Company/Group/Organization (if applicable)

How many members are in your Group

Are you fluent in a language other than English? If so, please list below.

What type of work are you comfortable/able to do?

Data Entry/Return CallsBasic landscaping dutiesBasic buildings maintenance itemsCleaning duties (floors, walls, surfaces, etc.)Visiting with residents at Mayors Manor

Please indicate the days and times you are usually available to volunteer.*

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning:
Afternoon:
Evening:

Where did you hear about our volunteer opportunities?

Emergency Contact First Name*

Emergency Contact First NameEmergency Contact Last Name

Emergency Phone Number*

Area CodePhone Number

Emergency Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I Agree

I understand and agree that submitting this application form does not automatically register me as a Mid Central Community Action, Inc. volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

Affidavit of Confidentiality:

Mid Central Community Action, Inc. adheres to the principle of maximum confidentiality and follows the mandates of the Illinois statutes and regulations as from time to time provided, and as currently specified in the Mental Health Confidentiality Act. Accordingly, all board members, staff, volunteers, and others associated with the operation of this agency shall keep all information regarding clients or agency business in general in strictest confidence. I understand the requirements for confidentiality and agree to abide thereby. I further understand that a violation of confidentiality requirements could result in immediate termination of my involvement with MCCA.

Media Agreement:

Volunteers give MCCA the right to use any images of any MCCA activities in which they participate in for both internal and external promotional and communication reasons.

Liability Waiver:

I release Mid Central Community Action, Inc. (MCCA) and its trustees, directors, officers, employees, agents, volunteers, successors, and assigns from any and all liability for, and waive any and all claims for, injury, loss, or damage in any way connected with my participation, including injury, loss, or damage caused in whole or in part by the negligence or other misconduct of MCCA or any of the above-listed organizations or individuals.

I am aware of the risks of participating, and assume all risks, foreseeable and unforeseeable, in any way connected with my participation. I agree to indemnify and to hold harmless MCCA and any of the above-listed organizations or individuals with regard to any claim or expenses (including attorneys’ fees and other costs of defending any claim by a third party or that I might make, or that might be made on my behalf) in any way connected with a claim.

Date*

MonthDayYear

Signature*

By signing this form, I attest that the information I have provided on the form is true and accurate and I have read and fully understand, agree to, and accept voluntarily all provisions of this Release of Liability and Waiver, Assumption of Risk, and Indemnification.