Montana Youth ChalleNGe Academy
790 East Cornell Street
Dillon, MT 59725
406-683-7559 / 406-925-9083
Fax: 406-683-7545
Service to Community Request Form
*Please complete a separate request form for each project needing our services.
Name of person requesting services:______Email:______
(Point of Contact)
Name of Organization: ______
(Must be non-profit)
Phone Number of point of contact: (Home) ______(Work) ______
Location of services needed: ______
Date, time, & hours services needed: ______
Number of cadets needed: ______
Description of services needed (Please be explicit and list any equipment you will provide):______
______
______
______
Please list any potential safety risks or hazards involved and any precautions you will provide: ______
______
______
I/we agree that ChalleNGe will not be liable for, and I agree to hold ChalleNGe harmless from any and all liability, causes of action and losses imposed on it in any way relating to or arising out of this service to the community agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my negligence, or ChalleNGe's negligence or otherwise.
I further release ChalleNGe from any and all liability, claims, demands or actions or causes of action whatsoever arising out of any damage, loss or injury I might incur while participating in any of the activities conducted in this service to the community agreement, whether such damage, loss, or injury is caused by the negligence of ChalleNGe, its officers, agents, servants, employees or otherwise.
In accordance with the policy of the Montana Youth ChalleNGe Academy, no alcohol or tobacco products are allowed in the vicinity of the ChalleNGe Cadets performing service to community for your organization. This policy is for the continued drug free environment that the Cadets have been in since their arrival at ChalleNGe. As well as providing a drug free environment, we will expect safety to be a primary concern for all requesting agencies. ChalleNGe Cadets are not authorized to ride in any vehicle unless it has been requested prior to the service to community and approved in advance. It is expected that as the Service to Community Sponsor, you will ensure that this environment exists for our Cadets. If you have any questions concerning this memo, please feel free to call Front office @ (406) 683-7556 or Deputy Commandant Perry Fosse at @
(406) 683-7514. In emergencies, please call the Team Leader on duty@ (406) 925-1572.
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Signature of Service to Community Requestor Printed name of Requestor Date
Please e-mail or fax this form Attn. Commandant Rod Viallon to…
/ Fax# 406-683-7545