Volunteer Application

FAIRBORN, OHIO CHAPTER

Building Hope in Our Community

VOLUNTEER APPLICATION, WAIVER OF LIABILITY & PARENTAL CONSENT FORM

Work day is Saturday, September 7th 2019

(Rain date is Saturday, to be determined)

**Applications MUST be received no later than September 1, 2019**

Please complete all lines completely - We will contact you by email or phone number if there are any changes
Full Name*

First NameLast Name
Home Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
E-mail
VOLUNTEER FOR THE FOLLOWING SKILLS:
Painting

YesNoLicensed or Skilled trade
Carpentry

YesNoLicensed or Skilled trade
Roofing

YesNoLicensed or Skilled trade
Landscaping

YesNoLicensed or Skilled trade
Dry Wall

YesNoLicensed or Skilled trade
Electrical

YesNoLicensed or Skilled trade
Masonry

YesNoLicensed or Skilled trade
Carpet Installation

YesNoLicensed or Skilled trade
Flooring

YesNoLicensed or Skilled trade
Plumbing

YesNoLicensed or Skilled trade
Other

YesNo
VOLUNTEER FOR THE FOLLOWING ACTIVITIES:
House team captain

YesNo
Transport supplies (Pickup truck, Van, SUV)

YesNo
Safety & First Aid (MD, RN, LVN, EMT)

YesNo
Assist with Pre and Post Work Day activities

YesNo
Other: (please explain below)

YesNo
Christmas in Action

Fariborn, OH. Inc.
T-Shirt Size:

SmallMediumLargeXLarge2XLarge3XLarge
Donate $5 for your shirt

YesNo
Address/Project assignment (Staff Entry Only)
Project Address:
Project #
Phone #
VOLUNTEER WAIVER OF LIABILITY - MUST BE FILLED OUT BY EVERY VOLUNTEER

Christmas in Action of Fairborn, OH. Inc. workday Saturday September 7, 2019

In consideration of the opportunity afforded me to assist on a voluntary basis in the "Christmas in Action of Fairborn, OH., Inc.", a project in which home repairs for low-income senior homeowners and low-income Fairborn resident homeowners will be completed by volunteers, and in light of the aims and purposes of the community service provided by Christmas in Action of Fairborn, OH., Inc. in organizing this project; I hereby waive any right or cause of action arising as a result of my participation in said project from which any liability may or could accrue against Christmas in Action of Fairborn, OH., Inc. or its officers and directors, employees, agents, donors, volunteers or other affiliates, collectively or individually. Without limiting the generality of the foregoing, I agree that this waiver shall include any rights or cause of action resulting from personal injury to me, death or damage to my personal property directly or indirectly arising from or sustained in connection with my activities for the CIA workday project.

I also grant Christmas in Action of Fairborn, OH., Inc. permission to take or have taken still and moving photographs and films including television pictures of myself. I consent and authorize Christmas in Action of Fairborn, OH., inc. its advertising agencies, news media and any other persons interested in Christmas in Action of Fairborn, OH., Inc and its works, to use and reproduce the photographs, films, and pictures and to circulate and publize the same by all means including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books and cilinical material.

I understand the success of the May 20, 2017 workday depends on my volunteer commitment. I realize my commitment is critical to help and complete the work that has been planned. I also realize that inclement weather is normally temporary and work will continue unless called off by Christmas in Action of Fairborn, OH., Inc. officers. Rain date is to be determined.
Signed this day of:

MonthDayYear
Full Name*

First NameLast Name
Signature*

Clear
PARENTAL CONSENT FORM (minors 12 - 17)

(Minors MUST return Signed Parental Consent form with their application and bring a 2nd COPY on Workday)
Minor's Full Name (First, Middle, Last)

First NameMiddle NameLast Name
Birthdate

MonthDayYear
The above named minor has my permission to participate in the Christmas in Action of Fairborn, OH., Inc. Home Repair Project, hereinafter referred to as Project, scheduled for September 7, 2019 or TBD (raindate). On behalf of such minor I have signed a Volunteer's Agreement and Release from Liability, hereinafter referred to as Release, and hereby agree to all of the terms and conditions of the Release. In case of medical or dental emergency, I understand that every effort will be made to contact me at the telephone number set forth below. If I cannot be reached, I hereby give my permission to the physician or dentist selected by Christmas in Action of Fairborn, OH., Inc. to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for the minor named above. A copy of this permission form may be accepted by andtreated by the physician to the original permission order.
Name of Parent or Guardian

First NameLast Name
Signature

Clear
Date of Signature

MonthDayYear
Parent or Guardian Phone Number

Area CodePhone Number
PLEASE COMPLETE THE FOLLOWING:
Name of Medical Insurance Carrier
Insurance Policy Number
Insurance Group Number
Minor's Primary Physician's Name

First NameLast Name
Primary Physician's Phone Number

Area CodePhone Number
Primary Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Minor's Dentist / Orthodontist

First NameLast Name
Dentist / Orthodontist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any Food or Drug Allergies and/ or Limitations on Activities
EMERGENCY CONTACT INFORMATION: The parent/guardian listed above will be the intial person to be contacted, please list two other individuals that can be contacted in case of an emergency.
First Contact Name

First NameLast Name
First Contact Phone Number

Area CodePhone Number
Relationship to Minor
Second Contact Name

First NameLast Name
Second Contact Phone Number

Area CodePhone Number
Relationship to Minor
Should be Empty: