Form
Volunteer Form
Please complete this form for our office records
Name
First Name
Last 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.
Date of Birth
Special Skills, Licenses/Certifications or Interests:
Languages Spoken
Emergency Contact Name & Number
Additional Emergency Contact Name & Number
Daytime Availability (check when you ARE available)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Evening Availability (check when you are available)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Who is your employer?
What is your occupation?
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Media Waiver
I hereby authorize Sojourner House, its licensees and assigns to broadcast and present my appearances, likeness and/or voice and to record my picture and/or voice (on photographs, film and/or tape), to edit these recordings at its discretion, to incorporate these recordings into a broadcast program, the internet and/or presentation and to use and to license others to use such recordings in any manner or media whatsoever including unrestricted use for purposes of publicity, advertising and sales promotion and to use my name, likeness, voice, biography or other information concerning me in connection thereto. I further acknowledge that Sojourner House owns all rights to the aforementioned recordings. I hereby agree to indemnify Sojourner House for all lose, damage, injury, liability whatsoever arising out of my appearance on the program. I also authorize Sojourner House to broadcast and present my appearance and/or voice and to record my picture and/or voice (on photographs, film and/or tape) to edit these recordings at its discretion.
E Signature - Type your Name
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Confidentiality Agreement
I, the undersigned, understand the necessity of maintaining confidentiality of Sojourner House's Programs at all times. This includes, but is not limited to, locations of residences, phone numbers, names and/or descriptions of our clients to anyone outside of Sojourner House. This is for everyone's safety and security with special attention to the adults and children to whom we provide services.
E Signature - Type your Name
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Liability Release Form
I, the undersigned, hereby release Sojourner House, its staff, volunteers, and Board members from any liability for any unintentional or negligent acts. I release them from any liability for any occurrances that may result in harm, physical injury, or damage to me, or my possessions while I am participating in agency programs. By signing below, I acknowledge that I understand and accept all the statements on this form with my signature.
E Signature - Type your Name
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Medical Release Form
If it is deemed appropriate by any member of the staff of Sojourner House, I hereby give permission to the personnel to seek medical treatment as necessary for myself at the nearest hospital and/or by ambulance in case of an emergency.
Date of Birth
-
Month
-
Day
Year
Date
Are there any medical conditions you'd like to disclose in order to receive the appropriate care in case of emergency?
E Signature - type your name
Submit
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