Volunteer Form: DIFFERENTREGARD

DIFFERENTREGARD Volunteer Application
Thank you for taking the time to complete this application. We look forward to working with you and appreciate your generous offer to share your time and talents with DIFFERENTREGARD. Please type or print clearly.
Age restrictions may apply to some volunteer placements.
Name:
Last First Middle
Address

Address

Street Address Line 2

CityState

Zip
Telephone
Home
Work
Cell
Email
example@example.com
Date of Birth

MonthDayYear
Date
Volunteer Information/Special Interests/Training
Have you been a volunteer with us before:

YesNo
If yes, where
When
Who was your supervisor?
Please summarize any special skills and qualifications you may have acquired from employment, previous volunteer work or through other activities, including hobbies or sports
Please check the area(s) in which you would like to volunteer. Select all that apply:
Clerical/Administrative (e.g., filing, answering phones, data entry)Special Projects (e.g., conducting research, writing reports, assisting with technical projects).Outdoor Activities (e.g., park beautification, litter cleanup, special events).Police (e.g., Volunteers in Police Service (VIPS).I am applying for a specific volunteer position(s):
I am applying for a court-ordered community service volunteer position.Other
Working with Specific Populations

YouthSeniorsFamiliesIndividuals with Disabilities
Note: Some volunteer positions may require a criminal background check before placement.
Schedule Preference

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Times available
Volunteer Application

Part 2
Do you speak and/or write any languages other than English?

YesNoIf yes, describe:
How did you hear about volunteering with DIFFERENTREGARD?

Select all that apply
Social MediaVolunteer Recruitment Event:
Word of MouthOther
References

Please provide the name, contact information and relationship to you of three personal or professional references that we may contact for additional information.

	PHONE	EMAIL	RELATIONSHIP TO VOLUNTEER

Are you able to perform the essential duties of the job for which you are applying?

YesNo
If no, please explain: Note: A disability will not prevent you from volunteering if you are able to perform the essential duties of the job with reasonable accommodations
Do you have any transportation barriers to consider?

YesNo
If yes, please describe
I understand it is my responsibility to share client information only with staff involved, to keep all information confidential and to report any information which may impact customers and/or co-workers.

I certify that this application is a complete record and that all entries and attachments are true and accurate to the best of my knowledge.
Volunteer Applicant Signature:

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If volunteer is less than 18 years of age:
Parent/Guardian's Signature

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Phone Number
Please enter a valid phone number.
Email
example@example.com
It is the intent of DIFFERENTREGARD to provide equal opportunity to all volunteers in all terms, privileges and conditions without regard to sex, race, religion, national origin, disability or any other factor.

All volunteers must comply with employment procedures of both Human Resources and the City Department. A criminal record does not automatically disqualify a volunteer from a work assignment. The nature of the offense and type of work in which the volunteer will be engaged will be taken into consideration before a decision is made. Human Resources and the City Department will confer in making the decision.
Participation Release of Liability and Assumption of Risk Agreement

***Read Entire Page Before Signing – Please Print***
Name of Activity/Program
Location
Fiscal Year: 20-
Fiscal Year 20 blanks -20
Participant Name:

First NameLast Name
Email
example@example.com
In consideration of being allowed to participate in any way in the program, related events and activities, I, the undersigned, acknowledge, appreciate and agree that:
1. The risk of injury from the activities involved in this program/activity may be significant, including the potential for permanent paralysis and/or death.
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS and assume full responsibility for my participation.
3. I willingly agree to comply with all terms and conditions for participation. I will comply with all safety policies and procedures. If I observe any hazard during my presence or participation, I will remove myself from participation and bring such information to the attention of the nearest Instructor immediately.
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS DIFFERENTREGARD CO, its officers, officials, agents and/or employees, other participants, sponsors and its officers, agents, servants and employees, advertisers and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”) from any and all claims, demands, losses and liability arising out of, or related to, any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, to the fullest extent permitted by law.
5. In the case of a life-threatening or serious accident or illness, I (parent or guardian) ask that the City contact me. In such case, I give permission for a rescue squad to transport my child to the closest medical facility. Should this occur, I give permission for the medical facility to treat my child at my expense.
6. In the case of a life-threatening or serious accident or illness, I give permission for a rescue squad to transport me to the closest medical facility. Should this occur, I give permission for the medical facility to treat me at my expense.
7. I give permission for me or my child to be videotaped or photographed while participating in the program or activity, and I give permission for DIFFERENTREGARD CO to use the videotape and/or photographs in brochures, newspaper articles, on the company's website, Facebook, Twitter on Public Television and in other local media outlets.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, I FULLY UNDERSTAND ITS TERMS, AND I UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Participants Signature

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Date

MonthDayYear
Date
For PARENTS/GUARDIANS of PARTICIPANT of MINOR AGE (under age 18 at time of participation): This is to certify that I, , as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release of all Releasees, as provided above of, and, for myself, my heirs, assigns and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incident to my minor child’s involvement or participation in this program/activity as provided above to the fullest extent permitted by law.
For PARENTS/GUARDIANS of PARTICIPANT of MINOR AGE (under age 18 at time of participation): This is to certify that I,blanks , as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release of all Releasees, as provided above of, and, for myself, my heirs, assigns and next of kin, I
release and agree to indemnify and hold harmless the Releasees from any and all liability incident to my minor child’s involvement or participation in this program/activity as provided above to the fullest extent permitted by law.
Parent/Guardian Signature

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Emergency Phone Number(s)
Please enter a valid phone number.
Date

MonthDayYear
Date
Should be Empty:

DIFFERENTREGARD Volunteer Application

Telephone

Volunteer Information/Special Interests/Training

Please check the area(s) in which you would like to volunteer. Select all that apply:

Volunteer Application

How did you hear about volunteering with DIFFERENTREGARD?

References

Participation Release of Liability and Assumption of Risk Agreement