VOLUNTEER STATEMENT AND REGISTRATION FORM Give to

Group #
Volunteer Statement and Registration Form
Give to center staff upon arrival.
Must be received by staff prior to volunteer participation in ASP activity
Appalachia Service Project (ASP) is a home repair and housing rehabilitation ministry. ASP operates in rural areas and cannot
guarantee the safety or sanitation of its work sites, accommodations, and facilities. Volunteers will be participating in home
repair and home building activities including, but not limited to: roofing, carpentry, dry wall installation, building steps,
plumbing, glasswork, insulating, painting, flooring, masonry, electrical wiring and other home repair, remodeling and
renovation. These activities include, but are not limited to: the use of power tools such as saws and drills, as well as the use
of hand tools. The foregoing activities will also require climbing with and without supplies, tools and materials as well as
working in high places such as on roofs and other facets of construction work. All volunteers, as well as these volunteers
and their parent(s)/legal guardian(s), must have read, be familiar with, and abide by ASP’s Safety Manual and Expectations,
Rules and Regulations. The minimum age for ASP volunteers is 14; however, 13 year old volunteers may participate if they
have completed the 8th grade. Volunteers may engage in non-sponsored activities including, but not limited to: hiking,
swimming, basketball, volleyball, baseball, football, Frisbee, or other sports activities of their choosing. Planned evening
activities may include, but are not limited to: visiting strip mines, traveling to visit places or people of regional interest.
Volunteers are not required to engage in any work or recreational activity in which they feel they are not able to safely
participate.
I give permission for treatment by competent medical personnel as a result of accident or medical emergency while involved
in the activities of ASP. Consent is given to accompanying adult volunteers on this trip to hospitalize, secure proper
treatment and to order injections, anesthesia, or surgery by qualified medical personnel. If possible, the adult contact will
make the final decision in cooperation with medical personnel. As ASP does not carry accident or medical insurance on
volunteers, I agree that my insurance company will be used for such medical care expenses and I am aware that I may be
billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not
have medical insurance coverage that I am responsible for the payment of any medical bills.
The foregoing statement of activities and the Appalachia Service Project information and guidelines (specifically ASP’s
Expectations, Rules, and Regulations and ASP’s Safety Manual) have been read and the extent and nature of the activities in
which you or your youth will participate are understood. If this Release is for a volunteer under the age of 18, the parent/legal
guardian’s signature below demonstrates that the parent/legal guardian has read this Release, the ASP guidelines and
manuals, and hereby gives his/her consent to allow the volunteer to participate in the activities outlined above and release
Appalachia Service Project, Inc., its agents, employees and any and all persons connected therewith are hereby released and
discharged from any and all liability, claims, and causes of action of any type whatsoever arising out of or in any way
connected with participation in the activities of the Appalachia Service Project, Inc.
Media Release and Waiver
The Volunteer and the Guardian grant and convey to ASP all right, title and interest in any and all photographic images and video or audio
records made during the Participant’s participation with Appalachia Service Project. The Volunteer and Guardian also hereby grant
permission for ASP to use photographs, videos, audio recordings, or to otherwise document Volunteer’s participation in ASP programs,
solely for the purpose of marketing, research and/or education. ASP will not identify by name any minors in either print or web-based
images.
Volunteers 18 years of age or older:
Volunteers under age 18 years of age:
Printed name of participant
______________________________________________________________
Printed name of participant
Participated with ASP before?
Yes
No
Participated with ASP before?
_____________________________________________________________
Signature
Date
Yes
No
________________________________________________________
Signature
Date
________________________________________________________
Date
Parent/Legal Guardian Signature
NOTARY REQUIRED: SIGN ABOVE IN PRESENCE OF NOTARY
, appeared before me
Name of participant (18 years & older) OR name of parent/guardian of minor participant
, a Notary Public of
(Notary’s name)
County in the State of ____________,
(County)
the person whose signature appears above and with whom I am personally acquainted or proved to me on the basis of
satisfactory evidence and acknowledge that he/she executed the instrument for the purposes therein contained.
Witness my hand and official seal this
day of
, 201
.
My commission expires:
(Notary Public)
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VOLUNTEER INFORMATION
Vol. Last Name _________________________________
First Name _______________________ MI ______
Nickname _____________________________________
Address ______________________________________
City, State, Zip _________________________________
Phone
Vol. Marital Status: single married widowed divorced
Birthday
Gender
(mon/day/year)
Male
Female
Occupation
Email address
EMERGENCY MEDICAL INFORMATION
Medical information on this form will only be used if medical treatment is needed. It will be used for no other purpose.
Social Security #
(optional)
Date of last Tetanus shot
Medication(s) you currently take (prescribed & over-the-counter – please list all – this is extremely important!!)
Medication(s) you CANNOT take
Any allergies &/or special health problems or concerns
Medical insurance information:
Company name
Phone
Address
City, State, Zip
Policy #
Policy Holder’s ID #
Relationship to policyholder
PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD WITH THIS DOCUMENT
In an emergency, please contact:
Name
Relationship
Address
City, State, Zip
Day Phone
Evening Phone
Cell Phone
Also on ASP?
Yes
No
Physician information:
Physician name
Name
Relationship
Address
City, State, Zip
Day Phone
Evening Phone
Cell Phone
Also on ASP?
Yes
No
Phone
In the event of an emergency or non-emergency situation in which medical treatment is required as a result of
participation with Appalachia Service Project, Inc., every reasonable effort will be made to contact the persons listed
above. If unsuccessful in contacting the persons listed, consent/permission is given for treatment by competent medical
personnel.
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