Liability Form 2022

Liability Waiver 2022

Last update 17 AUG 2022
If you would like access to OCB's Facility you must fill out this form. This form must be filled out in person at an OCB Facility witnessed by an OCB representative.

ANY FORM YOU MAY FILL OUT HERE ON OCB'S WEBSITE IS HIPAA COMPLIANT. YOUR INFORMATION IS PROTECTED.
Name*

First Name Last Name Suffix “Jr.” or “Sr.”
Date of birth*

MonthDay Year
Date
Gender - We collect this information to understand who is accessing our facility as part of our work to deliver inclusive programs that appeal to everyone in our community. Only intake / communications department / security / administration managers / medical professionals see these forms.

WomanMan
Phone Number*

Area Code Phone Number
Home Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email*
example@example.com
OCB Location that you are filling out this form*

Indiana-01Alabama-01California-01
Reason for visit*

I am a VeteranI am a first time VisitorI am a new Volunteer / InternI am a new Board Member
I agree that, anyone under the age of 18 is not permitted in dangerous or restricted areas (the shop). Volunteers / employees may not bring or accept visitors in areas where there are dangerous machines or chemicals, confidential records or sensitive equipment. Representatives of regulatory bodies, approved visitors, and donors (e.g. investors) may be exempted, if they have received official authorization from management and have first filled out this form prior to entering restricted areas. In these cases, employees / volunteers should provide visitors with the necessary badges and protective equipment to enter premises when needed.*

Yes
Age group*

18 - 2425 - 3940 - 5556 - 7070+
Branch of Service*

I am not a VeteranArmyUSMCAir ForceNavyCoast GuardSpace Force
Under current law, the VA recognizes the following wartime periods to decide eligibility for VA pension benefits: under which time did you serve?*

World War II (December 7, 1941, to December 31, 1946)Korean conflict (June 27, 1950, to January 31, 1955)Vietnam War era (February 28, 1961, to May 7, 1975, for Veterans who served in the Republic of Vietnam during that period. August 5, 1964, to May 7, 1975, for Veterans who served outside the Republic of Vietnam.)Gulf War (August 2, 1990, through a future date to be set by law or presidential proclamation). For VA benefits eligibility purposes, the Gulf War period is still in effect. This means that anyone who served on active duty from August 2, 1990, to present is considered a Gulf War Veteran.none of the above
Wartime Service?*

YesNo
Peacetime Service?*

YesNo
Combat Award?*

YesNo
Service Connected Disability?*

YesNo
In case of an emergency, please call*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.*

YES
OCB regularly takes pictures during shop day and at events. Do you grant us permission to use your likeness on OCB digital and print media?*

YES
I, the [applicant, requestor, etc.] for this [type of form], warrant the truthfulness of the information provided in this application.*

YES
OCB'S SHOP STANDARD OPERATING PROCEDURES HAVE BEEN EXPLAINED TO ME*

YES
Last 4 of your SSN*
Signature*

Clear
Witness*

First Name Last Name
Please verify that you are human*
Should be Empty:

Liability Waiver 2022

If you would like access to OCB's Facility you must fill out this form. This form must be filled out in person at an OCB Facility witnessed by an OCB representative.