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About
Cuba
Indy
June 18-23, 2017 | Week’s Schedule
June 18-23, 2017 | Housing
June 18-23, 2017 | Tool List
Contact
Support
Home
About
Cuba
Indy
June 18-23, 2017 | Week’s Schedule
June 18-23, 2017 | Housing
June 18-23, 2017 | Tool List
Contact
Support
1
Personal Information
2
Medical Information
3
Personal Skills
4
Volunteer Agreement
*** All fields must be completed *** If a given field is not applicable to you, simply put N/A to be allowed to continue to the next page.
Name
*
First
Middle
Last
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
*
Email
*
Church or Group Name
*
Team Leader Name
*
Date of Birth
*
Citizenship
*
I am an US Citizen
I am a non-US Citizen
Which day(s) are you wanting to volunteer?
June 19
June 20
June 21
June 22
June 23
*** All fields must be completed *** If a given field is not applicable to you, simply put N/A or 000-000-0000 to be allowed to continue to the next page.
Medical Information
Name of Medical Insurance Company
*
Name of Primary Card Holder
*
Group Number
*
Policy Number
*
Insurance Company Phone Number
*
Emergency Contact Person
*
Relationship
Emergency Contact Number
Alternative Number
*
Primary Care Physician Name
*
PCP Contact Number
*
Please list medicines currently being taken:
*
Please list medication and/or food allergies:
*
Please list pertinent medical history:
*
Personal Skills
*** All fields must be completed *** Please rate your skills on a scale from 0 to 5 (0 meaning no skill, 5 being the most skilled).
Cabinet Install
*
0
1
2
3
4
5
Interior Painting
*
0
1
2
3
4
5
General Carpentry
*
0
1
2
3
4
5
Plumbing
*
0
1
2
3
4
5
Vinyl Floor
*
0
1
2
3
4
5
Kitchen Remodeling
*
0
1
2
3
4
5
Interior Trim
*
0
1
2
3
4
5
Window Replacement
*
0
1
2
3
4
5
Drywall Install
*
0
1
2
3
4
5
Drywall Finishing
*
0
1
2
3
4
5
Siding Install
*
0
1
2
3
4
5
Concrete Finishing
*
0
1
2
3
4
5
Concrete Work
*
0
1
2
3
4
5
General Office Work
*
0
1
2
3
4
5
Tree Trimming
*
0
1
2
3
4
5
Shrub Trimming
*
0
1
2
3
4
5
Exterior Trim
*
0
1
2
3
4
5
Exterior Painting
*
0
1
2
3
4
5
Electrical Work
*
0
1
2
3
4
5
Roof Repair
*
0
1
2
3
4
5
New Roofs
*
0
1
2
3
4
5
Carpet Install
*
0
1
2
3
4
5
Landscaping
*
0
1
2
3
4
5
Gutter Install
*
0
1
2
3
4
5
Framing
*
0
1
2
3
4
5
Mechanic
*
0
1
2
3
4
5
Food Preperation
*
0
1
2
3
4
5
Bookkeeping
*
0
1
2
3
4
5
Check ANY that apply:
EMT/Paramedic
Medical Doctor
Dentist
Nurse
Licensed Counselor
Architect
Pro Web Designer
Computer Programmer
Engineer
Licensed Plumber
Licensed Electrician
Licensed HVAC
CDL
Information Technology
Volunteer Participant Agreement Form
Caution: This is a release of legal rights. Read carefully and understand it before signing.
Check to Agree
*
I freely choose to participate and/or allow my child to participate in the OHMH Indy 2017 project. For and in consideration of OHMH assisting, coordinating and facilitating my and/or my child’s voluntary participation in this Program, I agree as follows:
Risk Of Program Conditions
*
I understand that my and/or my child’s participation in this Program may involve strenuous physical activity.
Medical Release
*
I hereby give my team leader and/or leadership of One Heart – Many Hands permission to secure medical treatment for me in the event that I am not able to make that decision due to injury or illness. I also authorize release of any and all medical information which I receive pursuant to illness or injury to the aforementioned. In the case of a minor, I, the legal guardian, give permission to the aforementioned to secure immediate medical treatment for my child in the event of accident or illness. I also authorize release of any and all medical information which they receive pursuant to illness or injury treatment to the aforementioned.
Reporting
*
I agree to immediately report to the OHMH staff or other OHMH leadership any injuries, illnesses or emergencies that occur during the Program.
Institutional Arrangements
*
I understand that OHMH is not an agent of, and has no responsibility for, any third party that I and/or my child may provide any program services to. I understand that OHMH provides guidance and facilitates my and/or my child’s Program activities only as a convenience to participants and that accordingly, OHMH accepts no responsibility, in whole or in part, for loss, damage or injury to persons or property whatsoever, caused to me or others while participating in the Program. I further understand that OHMH is not responsible for matters that are beyond its control.
Institutional Arrangements
*
I understand that OHMH is not an agent of, and has no responsibility for, any third party that I and/or my child may provide any program services to. I understand that OHMH provides guidance and facilitates my and/or my child’s Program activities only as a convenience to participants and that accordingly, OHMH accepts no responsibility, in whole or in part, for loss, damage or injury to persons or property whatsoever, caused to me or others while participating in the Program. I further understand that OHMH is not responsible for matters that are beyond its control.
Photograph Release
*
I hereby consent to the photographing of myself and/or my child and the recording of my and/or my child’s voice and the use of these photographs and/or recordings for advertizing and publicity purposes for OHMH. I understand that the term “photograph” as used herein encompasses both still photographs and motion picture footage.
Assumption of Risk and Release of Liability
*
Despite precautions, accidents and injuries can and will occur. Therefore, I assume all risks related to the Program activities.
Check to Agree
*
I do hereby waive, release, covenant not to sue and forever discharge, to the fullest extent permitted by law, OHMH, all staff and project leaders and all related or connectional organizations, officers, agents, employees, representatives, successors, assignees and all others from any and all responsibilities, claims, expenses, personal injury, wrongful death or liability for injuries or damages of any kind arising from my and/or my child's participation in the any activities of the Program or arising out of participation in the Program. I do also hereby indemnify, release and hold harmless, to the fullest extent provided by law, all of those mentioned and others acting upon their behalf from any responsibility or liability for any injury, damage or death to my self and/or my child, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my and/or my child's participation in any activities connected with the Program.
Code of Conduct
*
I and/or my child agree to follow the leadership of OHMH staff and all Program policies and procedures provided by OHMH. I and/or my child will conduct myself/himself/herself in a responsible, appropriate and professional manner, including proper grooming and modest clothing and refraining from consumption, possession or use of alcohol, controlled or illegal substances or any controlled drugs other than prescribed medications while participating in the Program. I understand that volunteer participation is at the discretion of OHMH staff and project leaders and that volunteers who willfully and/or repeatedly disregard policies and the leadership of OHMH or affiliated organizations may be temporarily suspended from volunteer activities, or dismissed from the local project and sent home. This decision is at the discretion of the OHMH staff and/or team leader. The OHMH staff decision is final. I agree that if I and/or my child are dismissed, I will bear any additional expense in leaving the project.
E-Signature
*
I indicate by checking this box that I have read the terms and conditions of participation and agree to abide by them. I have carefully read this Release Form and acknowledge that I understand it. No representation, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. The Release Form shall be governed by the laws of the State of Kansas which shall be the venue for any lawsuits filed under incident to this Release Form or to the Program. If any portion of this Release Form is held invalid, the rest of the document shall continue in full force and effect.
Signer's Full Legal Name
*
Individual Registration - June 19
Price:
$45.00
Individual Registration - June 20
Price:
$45.00
Individual Registration - June 21
Price:
$45.00
Individual Registration - June 22
Price:
$45.00
Individual Registration - June 23
Price:
$45.00
OHMH T-Shirt Checkbox
I'd like to add $10 to my registration fee and receive a T-shirt to commemorate volunteering with One Heart Many Hands
What size shirt would you like?
S
M
L
XL
2XL
3XL
OHMH T-Shirt
*
Price:
$10.00
Total
$0.00
Credit Card
American Express
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Visa
Card Number
Month
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10
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Year
2021
2022
2023
2024
2025
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2027
2028
2029
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2031
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2034
2035
2036
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2039
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Expiration Date
Security Code
Cardholder Name
Name
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