St. Mary's Offsite Volunteer for Loaves and Fishes

St. Mary of the Lake Offsite Volunteer for Loaves & Fishes

ADULT LIABILITY WAIVER
Sponsoring Parish: Church of St. Mary of the Lake

Nature of Activity: Offsite Volunteer for Loaves & Fishes - Volunteers of St. Mary's who serve at an offsite location are required to fill out this offsite adult liability waiver. Volunteers on St. Mary's campus (either at the church building or PLC building do not have to complete these).

Individual(s) in charge: Peggy Parenteau (Volunteer Coordinator): 651-426-3088

Nathan Schuster (Manager of Mission) nschuster@stmarys-wbl.org

These records will be kept securely on file at the parish office. If you'd rather complete a paper version, please contact Nathan.

Name of Offsite Location: Catholic Charities Richard M. Schulze Opportunity Center

Address of Offsite Location: 422 Dorothy Day Place, St. Paul, MN 55102
Participant Name*

First NameLast Name
Phone Number*
This will be the main number used for communication about this event.
Type of number*

CellHomeWork
Email*
example@example.com; This will be the main email address used for communication about this event.

I First Name Last Name agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless, and defend St. Mary of the Lake Catholic Church, the Archdiocese of Saint Paul and Minneapolis, its officers, directors, agents, employees and representatives (“Releasees”) associated with the Activity from any and all liability claims, injury, loss and damage arising from or in connection with my participation in the Activity.

Further, I AGREE to hold Releasees harmless and indemnify Releasees for any claim or cause of action whatsoever, including but not limited to all claims relating to communicable disease, arising out of the above Activity which takes place during the above identified dates that is brought against Releasees by myself or my family members, heirs, assigns, executors, and personal representatives.

I UNDERSTAND that participation in the described activity involves danger and risk of injury. The inherent danger is understood and voluntarily assumed.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name.*

First NameLast Name
Date*

MonthDayYear
Date

Emergency Medical Treatment
If I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.*

Yes, I agree.No, I do not agree (I understand I will not be able to participate in this event).
Please advise the doctors that I have the following allergies and/or other health conditions:*
Incase of an emergency and for permission for treatment beyond emergency procedures, please contact: *

First NameLast Name
Relationship to me*
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Home/Alternate Phone Number

Area CodePhone Number
Health Insurance Carrier
Insurance ID Number
Insurance Policy Number

Submission Page
I HAVE READ THIS DOCUMENT. I UNDERSTAND ITIS AN AUTHORIZATION FOR MEDICAL TREATMENT, INDEMNIFICATION AGREEMENT AND RELEASEOF ALL CLAIMS. I UNDERSTAND I ASSUME ALLRISK INHERENT IN THIS ACTIVITY. I VOLUNTARILY SIGN MY NAME EVIDENCING MY ACCEPTANCE OF THESE PROVISIONS.*

Check here to agree.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name.*

First NameLast Name
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

St. Mary of the Lake Offsite Volunteer for Loaves & Fishes