SPHERE, Inc.

P.O. Box 1136

Ridgefield, CT 06877

DearProspective SPHERE Volunteer:

Thank you for your interest in volunteering for SPHERE, Inc. With the help and support of volunteers like you, SPHERE has developed into a wonderful, loving non-profit organization that will continue to grow with your help!

SPHERE’s mission is to enrich and enhance, through education, recreation and the arts, the lives of adults with a broad range of developmental disabilities while fostering and nurturing relationships between our members and our communities. SPHERE was founded over twenty-five (25) years ago to serve area adults with developmental disabilities. In 1989, SPHERE was certified by the Internal Revenue Service as a tax-exempt organization under section 501(c)(3) of the Internal Revenue Code.

Volunteer support allows us to present our participants to the community and the world as smart, talented and charming members of society; to educate the community that SPHERE members are employable, approachable and genuine contributors to our lives; and to provide recreational, educational and cultural programs to improve the quality of life for our SPHERE family and our community.

In order to ensure the safety of our members, SPHERE requires that all volunteers submit to a background check conducted by LexisNexis. All prospective volunteers must complete the attached application and return it to either Lori Berisford at or mail to the PO Box before the commencement of their volunteer duties. Approval of volunteer applications will be made on a case-by-case basis. The information gleaned in the application will be considered strictly confidential.

It is our goal and hope that, with increased involvement from our volunteers, we can continue to grow our organization efficiently and effectively, while engaging each other and our members in the areas that we are passionate about and which reflect our strengths.

We are all looking forward to another wonderful year of SPHERE!

Very truly yours,

Lori Berisford

President / Board Chair

SPHERE- NEW VOLUNTEER APPLICATION- 2016

(ALL FIELDS ARE REQUIRED)

Name

Address

/

Apt. Number

City

/

State

/

Zip Code

Home Telephone

/

Mobile Telephone

/ Date of Birth

Email Address

/ Social Security Number (required)

EMPLOYMENT

Present

/

Name of Employer

Length of Service

/

Title of Position

SKILLS & TRAINING

Special Skills or Training
Why do you want to volunteer at SPHERE?
Where did you hear about SPHERE?

AREAS OF INTEREST

Music & Performing Arts /  SPHERE-It Creations / Cooking Class
Open Gym & Swim
Game Night
Fundraising
OTHER (please explain): /  Bingo
 Membership Committee
 Special Events Committee /  Art Class
 Communications & Social
Media

REFERENCE

Name

Address

Phone Number

/

Relationship

E-mail

IN CASE OF EMERGENCY, PLEASE NOTIFY

Name

Address

Daytime Phone Number

/

Relationship

Have you ever been convicted of a crime in this state or elsewhere (not including traffic and parking violations)?
 Yes  No
(A conviction record will not necessarily be a strikeagainst your selection, and factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account).
SPHERE reserves the right to conduct state and federal background checks.

WAIVER AND RELEASE

  1. I agree to work as a volunteer for SPHERE, Inc. (“SPHERE”) and engage in activities related to being a volunteer.
  1. SPHEREhas my permission, both during and anytime after my volunteer tenure, to use my person, likeness and/or voice in either television, radio, film, newspapers, magazines, website, Facebook, online and other media, and in any form, for the purpose of advertising or communicating the purposes and activities of SPHERE and/or applying for funds to support those purposes and activities. SPHERE may use the likeness and voice of myself, alone or with others, by means of photograph, video, audio recording, or any other medium that exists now or in the future and is chosen by Sphere for use in promotional materials or publicity, or for any other legal use within the scope of Sphere’s purpose. This right to use includes the right to edit the likeness and voice. I understand my likeness and voice may appear in internal publications, promotional audio/visual presentations, or external publicity, including, without limitation, use in Sphere’s website, newsletters, annual report, or movies. “Use” also includes the right to use my name in connection with the likeness and voice.

I agree that I will l have no right to (i) pre-approve SPHERE’s use or editing of my likeness or voice as described above, (ii) claim compensation for SPHRE’s use of my likeness or voice as described above, or (iii) make any claims based on SPHERE’s use or discontinuance of use of my likeness or voice as described above, including any claims for libel, defamation or invasion of privacy. I agree that SPHERE will own all images and voice recordings taken or made by it or its representatives.
I understand that if my image or voice appears on SPHERE’s website or is otherwise distributed by SPHERE, it may be viewed, heard and copied by third parties. I waive any claims against SPHERE and agree not to hold SPHERE responsible for use of my likeness, voice, or name by third parties.
  1. I recognize that, due to the nature of this activity, an injury may occur. In the event of an injury to myself or a guest or a family member, I give permission to the called physician to render appropriate treatment and agree to pay for such treatment. I release SPHERE, Inc. and its employees, members, officers and directors from any liability arising out of any event or injury occurring during this activity, whether caused by the negligence of any third party and/or negligence or neglect of any volunteer or other participant. I expressly agree to assume all responsibility for attending these activities, including injury that might be sustained while participating, which includes coming to, leaving from and participating in any activity of SPHERE, Inc. I understand that this release applies to any present or future injuries or events or activities. I have read this statement and sign it voluntarily. I agree to provide a copy of this waiver to any and all family members or third parties who attend or participate in any activities or events involving SPHERE, Inc. that I invite or who come with me to view, participate in or attend any and all SPHERE, Inc. activities and events.
  1. If during the my participation in SPHERE activities, I should need emergency medical treatment, and I am not able to give consent or make arrangements for that treatment, I authorize SPHERE to take whatever measures necessary to protect the my health and well-being, including if necessary, hospitalization.
  1. It is agreed that all intellectual property and tangible property made during the course of SPHERE activities is the property of SPHERE, and will be retained and/or sold by SPHERE, subject to the discretion of the directors.
  1. I release and forever release, discharge and hold harmless SPHERE, Inc. and its successors, agents and assigns from any and all claims, actions, suits, procedures, cost expenses (including attorney’s fees and expenses), damages and liabilities arising out of, connected with, or resulting from travelling on the SPHERE Bus, including without limitation, those resulting from the conduct of myself and my companions.
  1. It is also understood SPHERE 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.
  1. I understand that SPHERE does not carry or maintain health, medical, disability or Workers Compensation insurance coverage for any volunteer.
  1. I agree that the terms and provisions of this Release are severable, meaning if a court holds any portion of this Agreement to be unenforceable, the validity of the remaining portion shall not be affected. I agree that this document shall be interpreted under Connecticut law.
  1. I have read this agreement and I fully understand it. This permission and release is binding on me and my heirs, legal representatives and assigns.

Signature / Printed Name Date

FOR SPHERE USE ONLY

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