New Customer Registration Form (Volunteer)

Full Name*

PrefixFirst NameLast Name

Gender

Do you already have a Parents' Night Out t-shirt?

YesNo

If not, what size?

Date of Birth

Age

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

At which location would you prefer to volunteer?

New Providence Baptist Church (Forsyth)Bibb Mt. Zion Baptist Church (Macon)

How would you prefer to be contacted?

PhoneTextEmail

In case of an emergency, who should we contact?

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Do you have any allergies or other medical concerns? If yes, please describe.

Have you ever volunteered at Parents' Night Out before?

YesNo

In which area(s) would you most like to volunteer?

List any skills or experience that may be applicable.

Do you have any of the following qualifications?

CPR CertificationFirst Aid CertificationFluent in Sign LanguageMedical Professional

Volunteer's Signature

First NameLast Name

In consideration of my participation in the Anchor of Hope Parent's Night Out Program, I acknowledge and agree to the following:

I am aware that the existence of my physical appearance at the venue and my participation in this activity may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

I have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

Myself, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.

Myself, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

I recognize that I may be at risk of contracting COVID-19.

With full knowledge of the risks involved, I hereby release, waive, discharge Anchor of Hope Foundation, New Providence Baptist Church, and/or Bibb Mount Zion Baptist Church, its board, officers, independent contractors, affiliates, employees, representatives, successors, assigns, and from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless Anchor of Hope Foundation, New Providence Baptist Church and/or Bibb Mount Zion Baptist Church from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) (Parent/Guardian's Signature (if volunteer is under the age of 18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Volunteer's Signature

First NameLast Name

I, on behalf of my child, hereby release and waive any and all claims for damages, injury, or death against either Anchor of Hope Foundation, New Providence Baptist Church, or Bibb Mt. Zion Church including their officers, directors, employees, agents, independent contractors, and staff that may accrue to me or my child as a result of my child’s participation in the Parent's Night Out program and agree to indemnify, protect, and hold harmless Anchor of Hope Foundation, New Providence Baptist Church, or Dayspring Presbyterian Bibb Mt. Zion Church including, but not limited to, personal injury, property damage, court costs, and attorney’s fees, however caused, as a result of my child’s participation in the Parent's Night Out program.

I am aware of that the risk from my child's physical appearance at the venue and participation in this activity may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

Myself, nor any member(s) of my householdhave not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

Myself, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.

Myself, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

I recognize that my child may be at risk of contracting COVID-19.

With full knowledge of the risks involved, I hereby release, waive, discharge Anchor of Hope Foundation, New Providence Baptist Church, and/or Bibb Mount Zion Baptist Church, its board, officers, independent contractors, affiliates, employees, representatives, successors, assigns, and from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless Anchor of Hope Foundation, New Providence Baptist Church and/or Bibb Mount Zion Baptist Church from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Parent/Guardian's Signature (if volunteer is under the age of 18)

First NameLast Name

Parent's Night Out Volunteer Registration