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Required fields are marked with an asterisk (*). One of the fields below is a file upload/attachment, the file size must be less than 10MB.Today's Date *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
First Name *
Last Name *
Home Street Address *
City *
State *
Zip Code *
Date of birth *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
Languages Spoken *
Emergency contact name *
Emergency contact phone number *
Relationship *
School or Organization You are Volunteering With (if applicable)
Interests *
Volunteer Location Site
Volunteer Commitment *
How did you hear about us? *
I hereby give my consent to all photographs, audio recordings, and/or video recordings taken of me, my minor child/children, or children for whom I am the legal guardian of, by Open Door Family Medical Center (Open Door) staff or their designee. I understand that any such photographs, audio recordings, and/or video recordings become the property of Open Door Family Medical Center for the purpose of promoting their organization in brochures, print, radio, print media, social media, and television media. There is no limit to how these images can be used for the publicity and promotion of Open Door.
I waive any and all rights that I may have against Open Door, any employee or representative of Open Door for the use of my picture or audio recording in the advertising and promotion of Open Door services, including any claims for damages or payment in connection with their use.
I understand that once my image has been printed or used in the development of a media campaign, that I cannot rescind consent. I can, however, rescind consent for the use in future media campaigns.
Media Release Consent *
Full Name of Applicant *
Waiver
This Release and Waiver of Liability (the "Release") executed today by ________ ("Volunteer") releases Open Door Family Medical Center (also referred to as ODFMC) a nonprofit corporation organized and existing under the laws of the New York State and each of its directors, officers, employees and agents. The Volunteer desires to provide services for ODFMC and engage in activities related to serving as a volunteer.
Volunteer understands that the scope of Volunteer's relationship with ODFMC is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; the ODFMC will not provide any benefits traditionally associated with employment to Volunteer,; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer's services to ODFMC.
1. Waiver and Release: I, release and forever discharge, and hold harmless ODFMC and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to ODFMC. I understand and acknowledge that this Release discharges Open Door Family Medical Center form any liability or claim that I may have against ODFMC with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to ODFMC or occurring while I am providing volunteer services.
2. Insurance: Further I understand that Open Door Family Medical Center does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of ODFMC.
3. Medical Treatment: I hereby Release and forever discharge Open Door Family Medical Center from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with ODFMC.
4. Assumption of risk: I understand that the services I provide to Open Door Family Medical Center are voluntary and carries with it certain risk that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another and may include but not limited to scratches, bruises, sprains, back injuries and broken bones. As a volunteer, I hereby expressly assume risk of injury or harm and acknowledge that my participation is voluntary and Release ODFMC of all liability.
5. Other: As volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of New York State and that this Release shall be governed by and interpreted in accordance with the laws of New York State. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected. By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.
This Release and Waiver of Liability (the "Release") executed today by ________ ("Volunteer") releases Open Door Family Medical Center (also referred to as ODFMC) a nonprofit corporation organized and existing under the laws of the New York State and each of its directors, officers, employees and agents. The Volunteer desires to provide services for ODFMC and engage in activities related to serving as a volunteer.
Volunteer understands that the scope of Volunteer's relationship with ODFMC is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; the ODFMC will not provide any benefits traditionally associated with employment to Volunteer,; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer's services to ODFMC.
1. Waiver and Release: I, release and forever discharge, and hold harmless ODFMC and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to ODFMC. I understand and acknowledge that this Release discharges Open Door Family Medical Center form any liability or claim that I may have against ODFMC with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to ODFMC or occurring while I am providing volunteer services.
2. Insurance: Further I understand that Open Door Family Medical Center does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of ODFMC.
3. Medical Treatment: I hereby Release and forever discharge Open Door Family Medical Center from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with ODFMC.
4. Assumption of risk: I understand that the services I provide to Open Door Family Medical Center are voluntary and carries with it certain risk that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another and may include but not limited to scratches, bruises, sprains, back injuries and broken bones. As a volunteer, I hereby expressly assume risk of injury or harm and acknowledge that my participation is voluntary and Release ODFMC of all liability.
5. Other: As volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of New York State and that this Release shall be governed by and interpreted in accordance with the laws of New York State. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected. By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.
