One Time Visit Form

INFORMATION

One-Time Volunteer Visit Form
First & Last Name*
Birthdate*

MonthDayYear
Date
Ethnicity*
Gender*

FemaleMale
I authorize Compassionate Heart Ministries to run a background check*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Email Address*
example@example.com
Emergency Contact (Full Name)*
Emergency Contact (Relationship)*
Emergency Contact (Phone Number)*
Volunteering Date*

MonthDayYear
Date
Volunteering Group/Team/Event Name:*
If applicable, if not, please remain blank
Have you ever been found guilty of a felony or misdemeanor? If yes, please explain:*
Have you ever received a sentence or probation through a juvenile court? If yes, please explain:*
Waiver/Release/Consent & Agreement & Code of Ethics Form
Please Initial (Medical Care & Medications)*
I, in the event of an emergency, give permission to Compassionate Heart Ministries to secure proper emergency treatment and/or medical treatment. I understand that Compassionate Heart Ministries does not provide medical care. Further, Compassionate Heart Ministries will not administer any prescribed or over-the-counter medications.
Please Initial (Release of Information)*
In the event of a medical emergency, I give consent to Compassionate Heart Ministries to release any information or documentation to health care providers/agencies/or organizations.
Please Initial (Personal Property)*
I understand and agree that Compassionate Heart Ministries is not responsible for the loss or damage to any personal property.
Please Initial (Release of Visual Images or Audio Recordings)*
I agree that Compassionate Heart Ministries may use and/or reproduce all photographic, video, or audio in any form of myself for display, marketing, or promotional materials.
Please Initial (Liability Waiver/Release/Hold Harmless/Indemnity Agreement)*
I acknowledge that Michigan law does not permit me to waive my legal rights, however in consideration for allowing me to participate in activities sponsored or provided by Compassionate Heart Ministries, I agree that Compassionate Heart Ministries, their agents, officers, employees, trustees, volunteers, and/or the heirs, administrators, executors, and assigns of the above-named entities and individuals, will not be liable for any and all claims and liabilities of any kind. Further, I agree to hold harmless, indemnify, and reimburse for any damage award, actual attorney fees, and costs incurred by Compassionate Heart Ministries, their agents, officers, employees, trustees, volunteers, and/or the heirs, administrators, executors, and assigns of the above-named entities and individuals, from any and all legal claims brought on by me (us) or my (our) agents, heirs, administrators, executors, and assigns or by the participant, their agents, heirs, administrators, executors, and assigns for any cause which arises from the activities sponsored or provided by Compassionate Heart Ministries.
Compassionate Heart Ministries Code of Ethics
- I will treat all volunteers, staff, and participants with mutual respect, be honest with one another, and work to build each other up Christ.
- I will model and encourage appropriate behavior with all individuals I encounter.
- I will follow the directions given to me from all Compassionate Heart Ministries staff.
- I will refrain from using profanity and abusive or threatening language.
- I will refrain from public displays as defined as "any touch intended to arouse feelings of love in the giver and/or the recipient".
- I will not wear revealing, immodest clothing, or clothing with offensive slogans, messages, or political propaganda.
- I understand that matches/lighters are not allowed.
- I will not use or be in possession of legal, illegal, or harmful substances of any kind (tobacco products, alcohol, drugs, etc
- I will not be in possession of weapons of any kind, including pocketknives.
- I understand that explosives of any kind are not allowed (i.e., fireworks, pop bottle bombs
- I will not engage in illegal or harmful behavior to myself or others.
/ understand the Waiver/Release/Consent and Agreement Form and sign with full knowledge of its legal consequences and without coercion or duress.

/ have read and understand all the Codes of Ethics.
Parent Signature (if under 18 years old)

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Date Signed:

MonthDayYear
Date
Volunteer Signature*

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Date Signed:*

MonthDayYear
Date
S:/Shared/Volunteers/Volunteer Forms/Current Forms/One Time Volunteer Visit Form
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INFORMATION

Waiver/Release/Consent & Agreement & Code of Ethics Form

Compassionate Heart Ministries Code of Ethics