Advisory Committee Application

Advisory Committee Application

Thank you for your interest in participating on this committee! This committee will meet quarterly with the Executive Director at our main office building. The purpose of these meetings is to get feedback on programs, learn about additional community resources that we could be directing families to, and gain insight on the kinds of support (programs, events, etc.) that our families might want to see. Parents of children in our programs, volunteers, and Ambassadors are invited to participate on this committee. Must be at least 18 years of age to be on the committee.
Applicant Name*

First NameMiddle NameLast Name
Gender*
What is your relationship to the Foundation?*
Parent, volunteer, Ambassador, etc.
Email Address*
example@example.com
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please tell us why you would like to be part of the advisory committee.*
Informed Consent

I, the undersigned applicant, voluntarily submit this application to be considered for participation on an advisory committee organized by the Carrie Tingley Hospital Foundation.

If selected, I acknowledge that my role as an advisory committee member may include participation in meetings, discussions, planning sessions, virtual or in-person events, and related activities. I understand that participation is voluntary and that I may withdraw at any time.

I acknowledge and voluntarily assume any minimal risks associated with participation, including but not limited to time commitment, exposure to differing viewpoints, and participation in meetings where perspectives/commentary shared by other participants may be mature, offensive, or objectionable in nature.

I hereby release, indemnify, and hold harmless the Carrie Tingley Hospital Foundation, its officers, employees, agents, volunteers, and affiliated entities from any and all claims, liabilities, damages, or losses arising out of or related to my participation on the advisory committee, except in cases of gross negligence or willful misconduct.

I understand that participation on the advisory committee does not create an employment relationship and does not entitle me to compensation unless otherwise expressly stated in writing by the Foundation.

Photo/Video Waiver

In consideration of my participation as an advisory committee member, I hereby grant permission to the Carrie Tingley Hospital Foundation and its affiliates to photograph, record, or otherwise capture my image, likeness, voice, and/or participation during advisory committee activities.

I authorize the use of such materials for purposes including, but not limited to, reporting, education, and publication in print, digital, or electronic media. I understand that no royalty, fee, or other compensation will be provided for the use of these materials.

I acknowledge that this release is voluntary, has no expiration date, and is not limited by geographic location.
Confirmation

By signing and dating below, I confirm that the information provided on this form is true and accurate to the best of my knowledge. By signing and dating below, I agree to abide by the waivers and releases listed above. I acknowledge that by submitting my electronic signature, it carries the same legal effect as a handwritten signature and is equally binding.
Signature*

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Date Signed*

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Advisory Committee Application

Confirmation