**PLEASE PRINT, FILL-OUT, AND BRING WITH YOU WHEN VOLUNTEERING**

The Green Chair Project Volunteer Registration Form

The Green Chair Project welcomes volunteers ages fifteen and older.  Thirteen and fourteen year olds are welcome if they are accompanied by a parent/guardian. at all times.  A signature on the following waiver/release is required prior to commencing volunteer activities.  Modified waivers cannot be accepted.

Section 1- Please Fill out the following information completely              Today’s Date  _________________

 

First Name:

Last Name:

Preferred Name (is there a nick name you would like us to call you?)

 

Street Address:

 

 

City:

Zip Code:

 

 

 

E-mail address:

 

 

Phone Number

Alternative Phone Number (e.g.- Cell Phone)

 

 

Birth Date (Day/Month)

Do you have any restrictions or conditions that we should know about?

Do you have any allergies that may affect you while volunteering e.g.- (food, chemicals)

 

Emergency Contact’s First Name

Emergency Contact’s Last Name

Emergency Contact’s Phone Number (s)

 

 

 

Section 2 - For Minors ages 13-17 only

 

Parent/Guardian’s First Name

 

 

Parent/Guardian’s Last Name:

Your Age:

Parent/Guardian’s E-mail address:

 

 

Parent/Guardian’s Phone Number

Parent/Guardian’s Alternative Phone Number (e.g.- Cell Phone)

 

Section 3- Release and Waiver of Liability for Volunteers (Parent/Guardian signature required for all minors)

 

In connection with my volunteer activities related to The Green Chair Project (the “Project”), organized by The Green Chair Project, Inc. (the “Company”) for myself, my personal representatives, assigns, heirs, and next of kin, I hereby:

 

1.            ACKNOWLEDGE, agree, and represent that I understand the nature of the Project’s activities and my responsibilities therein and that I am qualified and able to serve as a volunteer for the Project.            I further acknowledge that I will comply with any and all policies and procedures of the Company at all times. I further agree and represent by my signature below that, to my knowledge, I have not been the subject of any investigation, complaint or legal action involving a reported instance of sexual abuse, and I have never been refused, resigned from, or been asked to resign from a position for reasons related to such sexual abuse;

 

2. RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the Company, its administrators, directors, agents, officers, members, volunteers, employees, sponsors, advertisers, and, if applicable, owners and lessors of the premises on which the activities of the Project take place (the “Releasees”) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise; and I further agree that if, despite this release and waiver of liability, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim. I assume all risk of personal injury while on or around the Company’s premises. Any personal items I bring onto the Company’s premises will be at my own risk and the Company will not be liable for lost, damaged or stolen items. I also understand that the Company 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 or illness.            I do hereby release and forever discharge the Company from any claim whatsoever which arises or may hereafter arise on account of any services rendered in connection with my volunteer activities in connection with the Project;

 

3.            ACKNOWLEDGE that (i) as a part of my volunteer activities for the Company, I may provide my image, likeness, voice, or other characteristics; and (ii) the Company may use my image, likeness, voice or other characteristics.            I expressly release the Company, its administrators, directors, agents, officers, members, volunteers, and employees from and against any and all claims which I have or may hereafter have for invasion of privacy, right of privacy, defamation, copyright infringement or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such characteristics; and

 

4.            ACKNOWLEDGE that, as a volunteer for the Company, I may receive personal, privileged, and/or confidential information concerning clients, clients’ family members, and other individuals and organizations with whom the Company is associated. I agree and represent by my signature below that I will use my best efforts to ensure that such personal, privileged, and/or confidential information remains confidential and is not disclosed, regardless of whether I am actively engaged in volunteer activities or whether my volunteer involvement with the Company has ended for any reason.

 

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. I expressly agree that the foregoing release, waiver and indemnity is intended to be as broad and inclusive as is permitted by the law of the State of North Carolina and that if any portion of this Agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further authorize and allow the Company to perform any background check on me,

in accordance with state and federal law.            I UNDERSTAND THAT NOTHING IN THIS RELEASE OR IN THE SERVICES PERFORMED BY ME SHALL BE CONSIDERED TO CREATE THE RELATIONSHIP OF EMPLOYER AND EMPLOYEE BETWEEN THE COMPANY AND ME.

Printed name of volunteer: ______________________________ Volunteer’s signature (only if age 18 or over):            __________

Date: _______________________

 

MINOR RELEASE            [FOR USE IF ANY VOLUNTEER IS UNDER THE AGE OF 18]

I, THE MINOR’S PARENT and/or legal guardian, understand the nature of the Project (as defined above) and the minor’s experience and capabilities and believe the minor to be qualified and able to serve as a volunteer with the Project. I hereby release, discharge, covenant not to sue, and agree to indemnify and save and hold harmless each of the Releasees (as defined above) from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, and further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the Releasees named above, I will indemnify, save, and hold harmless each of the Releasees from any litigation expenses, attorney fees, loss liability, damage, or cost any may incur as the result of any such claim.

Printed name of parent/guardian: _______________________________ Phone: ____________________ Address: ___________________________________________________________

(Street)            (City)            (State)            (Zip) Printed name of minor: ________________________________ Parent/guardian’s signature (only if volunteer is under age 18) _____________________ Date: ________________

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