Please provide the following information • All fields marked with * are required.
Date of App:
*Name:				*Last Name:
Address:				City:
State:		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		Zip Code:
Home Phone:				Work Phone:
Cell Phone:				Fax:
Email:
Emergency Contact:
Phone:				Cell Phone :
Age Gategory:		(18-30) (31-45) (46-60) (61 and over)
If an intense oil clean up class is offered, would you participate?
		yes no
Are you aware of any condition that would prohibit or limit you from performing your duties?
		yes no
Please explain:
What would you like to volunteer for?
		Long Term Volunteering
		Disaster Relief-VRC (Volunteer Receprtion Center)
		Projects (as needed)
		Court Ordered Community Hours:Amt needed:
		Reason for hours:
When Are You Available?		Weekdays Weekends Mornings Afternoon Evening
Medical:		Doctor Nurse EMT Mental Health Vet Vet Tech
Communication:		CB HAM PR Web Design
Language other than english:
Office Suppor:		Clerical Data Entry Phone Receptionist
Software:		MS Word WordPerfect Excel Internet Email
Services:		Food Elderly Disabled Child Care Ministry
		Social Work Search & Rescue Auto Repair/Towing Traffic Control
		Crime Watch Animal Rescue/Care Hospice
Structural/ Construction:		Damage Assesment Metal/Wood/Block Construction
Re tail/Sales:		Cashier Stock Salesperson Inventory
Transportation
A ble To Drive?<		yes no
Valid Drivers License State:		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		Commercial Class:
Labor:		Loading & Shipping Sorting & Packing Cleanup
Equipment:		Backhoe Chainsaw Generator Other:
Are you aware of any condition that would prohibit or limit you from performing your duties?
Release of Liability
County, local governments, State of Florida, the participating agencies, the coordinating agencies, the organizers, sponsors, and supervision of all activities from all liability for any and all risk of damage or bodily injury or death that may occur to me (including any injury caused by negligence), in connection with any volunteer efforts in which I participate. I will abide by all safety instructions and information provided to me during any and all volunteer efforts. I give permission to have my photograph taken and used in whatever way desired by United Way of Hernando County, Inc. including audio/visual projections, print media and television; furthermore, I hereby consent that such photographs and the plates from which they are made shall by their property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs as they may desire, free and clear of any claims whatsoever on my part. Further, I expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as my own free act.
Signature:
Date:
Guardian If Under 18:
Date: