Volunteer Application Information & Waiver

Date: ______

Name (please print clearly): ______Date of Birth:______

Address:______City: ______State: ______Zip:______

Home Phone: ______Cell Phone: ______

Business Phone: ______Email:______

Emergency Contact Name: ______Relationship to you: ______

Emergency Contact Phone #: ______Alternate Phone #: ______

Employer/Occupation: ______

Does your current Employer match the hours you donate as a volunteer? Yes No Don’t Know

How did you learn about volunteering with LCSA? If referred, by who?______

Availability:

How many hours in total are you interested and available to volunteer (weekly/monthly)? ______

Please enter your hours of availability to volunteer:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

Special Skills (Fluency in another language, trainings, certifications, professional skills, talents/abilities)

______

______

Have you been arrested or convicted of a crime in the last 5 years?YesNo

If yes, please list the nature, reason, and date of arrest or conviction below or ask to speak with an LCSA staff member.

______

List any concerns or special requirements that you would like us to consider when selecting a position for you (physical and other limitations, timesheet for college credit or work, court ordered community service etc.)______

______

ASSUMPTION OF RISK AND RELEASE FROM LIABILITY AGREEMENT

PLEASE READ CAREFULLY. THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

I, ______desire to provide volunteer assistance to Labor’s Community Service Agency (LCSA). Therefore, as a precondition to joining LCSA as a volunteer, I hereby agree as follows:

  1. I shall serve LCSA as a volunteer or intern, I shall work for LCSA and my work product shall belong to LCSA. I shall not receive compensation or other benefits usually afforded the employees of LCSA.I shall comply with the business and office policies of LCSA.
  2. I shall not disclose any matters of a confidential nature regarding LCSA or its clients to which I may be or become privy in connection with my volunteer services to LCSA.
  3. I shall work for LCSA at my own risk, and I agree that I, my heirs, personal representatives, and assigns, will not make a claim or bring a lawsuit against LCSA or its directors, officers, agents, employees, volunteers, suppliers, contractors, subcontractors, or attorneys (the “Released Parties”) for injuries, illnesses or damages resulting from the negligent or intentional acts or omissions of the Released Parties. I waive and release the Released Parties from all actions, claims, or demands.
  4. I agree to indemnify and hold harmless the Released Parties from any and all loss, liability, claims, damages, costs and expenses (including attorneys’ fees) resulting from or relating to, in whole or in part, my participation as a volunteer in home rehabilitation, landscaping and other activities of LCSA.
  5. I agree to grant to LCSA the irrevocable and unrestricted right to use and publish photographs/video of the individual named above, or photographs/video in which he/she may be included, for editorial trade, advertising and any other purpose and in any manner and medium; and to alter the same without restriction. I hereby release LCSA, its directors, officers, employees, agents, volunteers and the photographer from all claims and liability relating to or arising out of the use of said photographs/videos.
  6. LCSA reserves the right to terminate my volunteer services or internship arrangement at any time, with or without cause or notice, and for any legal reason or for no reason.
  7. I expressly agree that this Agreement is intended to be as broad and inclusive as permitted by the laws of the State of Arizona and that this Agreement shall be governed by and interpreted in accordance with the laws of the State of Arizona.
  8. In the event of any claim, suit or dispute relating to this Agreement or any of the activities or other matters described in the Agreement, I agree that such disputes shall be settled by binding arbitration in the City of Phoenix, in accordance with the rules then prevailing of the American Arbitration Association instead of a trial.

Entire Agreement and Enforceability. This Agreement is the entire agreement and understanding between LCSA and me. This agreement may not be changed, waived, discharged, or terminated unless agreed to in writing by LCSA and me. I agree that in the event that any clause, sentence, or provision of this Agreement shall be held to be invalid by any court of competent jurisdiction, the validity of that clause or provision shall not otherwise affect the remaining provisions of this Agreement which shall continue to be enforceable. This Agreement is binding upon me and my heirs, personal representatives, and assigns, and any other person making a claim on my behalf. In addition, if I am a married person, I agree that this Agreement is made by me on my behalf and on behalf of the marital community of my spouse and me, and I agree that this Agreement will be binding on that marital community.

Participant Signature:

x______(Date)______

If you are under 18 years of age, it is required that your parent/guardian sign this document.

Parent/Guardian Signature:

x______(Date)______