Carrie On Volunteer Signup
Name
*
First Name
Last Name
Address
*
Street Address
Mailing Address
City
State / Province
Postal / Zip Code
Primary Email Address
*
example@example.com
Primary Phone Number
*
-
Area Code
Phone Number
Have you ever been convicted of a crime? If yes, please explain the nature of the crime and the date of the conviction and disposition. (Conviction of a crime is not an automatic disqualification for volunteer work)
*
Do you have a history of drug or alcohol abuse? If yes, please explain dates of abuse and what treatment and resolution was reached. (Substance abuse history will not automatically disqualify volunteers!)
*
DOB:
If completing for minor, please complete the following section, if for yourself leave blank:
First Name:
Last Name
DOB:
Emergency Contact:
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Can this person pickup your child?
Yes
No
References
Please list two people who know you well and can attest to your character, skills, and dependability. If completing for minor please include reference for minor only.
Reference
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Release Of Liability and Confidentiality Waiver for Adults & Minors
This release and Waiver of Liability executed on the date stamped on this application, by legal guardian or self, in favor of Carrie On NC, Inc., a nonprofit corporation organized and existing under the laws of the State of North Carolina, USA. and their directors,officers, employees, and agents (collectively, “Carrie On NC, Inc.”). The Minor or self, desires to work as a volunteer for Carrie On NC, Inc. and engage in the activities related to being a volunteer. I hereby freely and voluntarily, without duress, execute this Release under the following terms: 1. Waiver and Release. The parent and/or self release and forever discharges and hold harmless Carrie On NC, Inc. and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the minor’s volunteer work at Carrie On NC, Inc. The parent/self understands and acknowledges that this Release discharges Carrie On NC, Inc. from any liability or claim that the parent and minor may have against Carrie On NC, Inc. with respect of bodily injury, personal injury,illness, death, or property damage that may result from participation in Carrie On NC, Inc. volunteer work. It is also understood that Carrie On NC, Inc. does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance in the event of injury,illness, death or property damage 2. Insurance. The parent and/or volunteer understands that we expressly waive any such claim for compensation or liability on the part of Carrie On NC, Inc. beyond what may be offered freely by the representative of Carrie On NC, Inc. in the event of such injury or medical expense. 3. Medical Treatment. The parent and/or volunteer hereby release and forever discharge Carrie On NC, Inc.from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during the minor’s time with Carrie On NC, Inc 4. Assumption of Risk. The parent of the said minor and/or self recognizes and understands that the time with Carrie On NC, Inc. may,in some situations, involve situations in which risks could be associated with the named activities. I hereby expressly assume the risk of injury or harm in these activities and release Carrie On NC, Inc. from all liability for injury, illness, death or property damage resulting from the activities of the minors time at Carrie On NC, Inc. 5. Photographic Release. I grant and convey unto Carrie On NC, Inc. all right,title, and interest in all photographic images and video or audio recordings made by Carrie On NC, Inc. during the work with Carrie On NC, Inc. 6.Other. As the volunteer or person acting in a parental role I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of North Carolina in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the State of North Carolina. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall no otherwise affect the remaining provisions of this Release which shall continue to be enforceable
Person Completing Form:
*
First Name
Last Name
Electronic Signature:
*
Submit
Should be Empty: