Volunteer Information Form

Full Name *

First Name Last Name

Date of Birth *

Month Day Year

First day of service *

Month Day Year

Last day of service *

Month Day Year

Please indicate whether you will stay in the volunteer house or elsewhere during your time volunteering with us *

Volunteer house I have other accommodations

School/Group (If Applicable)

If you are in a group, indicate how many people you are traveling with. Otherwise fill '1' *

Occupation *

note if student, retired, full-time homemaker, etc.

Do you have any prior experience or skill sets that might be useful on a work site?

Yes No

Please describe any skills or experience you have:

Permanent Home Address (not dorm) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Permanent E-mail (not school or work) *

Please indicate any allergy, health concerns, or physcial limitations we should be aware of.

Have you had a tetanus shot and up-to-date booster shot(s)? *

Yes

Will you have health insurance (or travel insurance with medical expense coverage) valid in the USA throughout your dates of service? *

Yes

Disclaimer Clause

lowernine.org, its directors and employees, are not responsible for any injury, loss or damage of any kind sustained by any person while participating in the "lowernine.org Rebuild Program" in New Orleans, LA and all related activities, including injury, loss or damage which might be caused by the negligence of lowernine.org. I hereby grant full permission to use my name and image in any photographs, videotapes, motion pictures, recordings, broadcasts, or other record of my service with lowernine.org.

I freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury, death, permanent disability, property damage or loss resulting thereof.

I freely accept and assume all responsibility to provide myself with medical/health and travel insurance coverage.

Indemnification and Release of Liability

In return for lowernine.org allowing me to voluntarily participate in the "lowernine.org Rebuild Program" in New Orleans, LA and all related activities, I agree:

To assume and accept all risks arising out of, associated with, or related to my participating in the "lowernine.org Rebuild Program" in New Orleans, LA and all related activities, even though such risks may have been caused by the negligence of lowernine.org;

To hold harmless and indemnify lowernine.org from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my participation in the "lowernine.org Rebuild Program" in New Orleans, LA, and from any and all claims, demands, actions and costs which might arise of my participating the "lowernine.org Rebuild Program" in New Orleans, LA and all related activities.

I am above the age of 18 and acknowledge that I have read and agree to the terms and conditions stated above. *

I am the legal guardian of the person(s) referenced in this form and acknowledge that I have read and agree to the terms and conditions stated above.

Date signed *

Month Day Year

Emergency Contact Info *

First Name Last Name

Phone Number *

Area Code Phone Number