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All fields marked with * are required.
To let us better serve you, please complete this form and a representative from
United Way of Hernando County will contact you.
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*Name: |
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*Last Name: |
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*Address: |
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*City: |
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*Email: |
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*State: |
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*Zip: |
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*Home Phone: |
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*Work Phone: |
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*Cell Phone: |
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*Fax: |
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*Emergency Contact: |
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*Home Phone: |
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*Cell Phone: |
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Age Category: |
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Please list what opportunities you are interested in: (visit our website for participating agencies) |
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3.
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When are you available? |
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Are you aware of any condition that would prohibit or limit you from performing your duties? |
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Please explain: |
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When are you available? |
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Amount Needed:
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Special Skills: |
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Medical: |
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Communications: |
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Languages othe than english: |
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Office Support: |
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Software: |
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Services: |
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Structural/
Construction: |
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Retail/Sales: |
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Transportation: |
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Valid Driver's License: |
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Commercial Class: |
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Labor: |
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Equipment: |
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List any other special skills not listed: |
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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.
Please check:
I have carefully read the foregoing release and indemnification and
I understand the contents.
Submitting this form is your digital
signature and you sign this release as your own free act. |
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