to the forms

WV Ministry of Advocacy and Workcamps Inc.
(For All Volunteers - Please fill out both pages and return two months prior to your trip.)
I, _____________________________, acknowledge and state the following: I have chosen to travel to the
work site to perform cleanup/construction work in disaster relief. I understand that this work entails a risk
of physical injury and often involves hard physical labor, heavy lifting, and other strenuous activity; and
that some activities may take place on ladders and building framing other than ground level. I certify that I
am physically able to perform this type of work.
I understand that I am engaging in this project at my own risk. I understand that this is a “grass roots”
activity to support individuals adversely affected by the disaster. I assume all risk and responsibility for any
damage or injury to my property or any personal injury that I may sustain while involved in this project,
and related material costs and expenses.
In the event that West Virginia Ministry of Advocacy and Workcamps, Inc. arranges accommodations, I
understand that they are not responsible or liable for my personal effects and property and that they will not
provide lockup or security for any items. I will hold them harmless in the event of theft or for loss resulting
from any source or cause. I further understand that I am to abide by whatever rules and regulations may be
in effect for the accommodations at that time.
By my signature, for my estate my heirs and myself I release, discharge, indemnify and forever hold West
Virginia Ministry of Advocacy and Workcamps, Inc., together with their officers, agents, servants and
employees, harmless from any and all causes of action arising from my participation in this project, and
travel or lodging associated therewith, including any damages which may be caused by their own
negligence. I also give permission for my picture to be used in West Virginia Ministry of Advocacy and
Workcamps, Inc., publicity.
Signature: ___________________________________ Date: __________________
For more information, go to
Page 1 of form
MEDICAL INFORMATION:(Your confidentiality will be respected.)
* If you will be driving volunteers, please enclose a copy of your Driver’s License.
Participant Name ___________________________
Address ____________________________
City ________________________ State ______________ Zip Code ___________
Phone Number ______________________
Date of Birth ______________ Age ____________ Gender: M / F
Emergency Contact Name ___________________________
Emergency Contact Phone Number ______________________
Insurance Company Name _____________________________
Insurance Policy Number (if applicable)___________________________
Insurance Policy Group Number (if applicable)_______________________
Date of last tetanus shot_____________ Blood type (if known)____________
Please indicate if you have experienced health problems with the following:
Ear trouble____
Sinus trouble____
Heart disease____
Cramps in water___
Epileptic seizure_
Rheumatic Fever___
Allergies (Please list type and treatment necessary)
Please indicate any items that need to be avoided (such as paint fumes, heights, poison ivy,
Other significant illnesses____________________________________________
Any and all health/medical information supplied above is for exclusive use of WVMAW and its agents (all supervising personnel).
By signing the Liability Release Form, I give permission for this information to be used in planning for and supervising my
participation while in West Virginia.
Page 2 of form
What is your usual occupation?__________________________________________
Please indicate on this form your approximate level of skill using 1-4 to grade experience as listed below:
1 - Can supervise or teach this activity
2 - Able to competently perform this activity
3 - Could perform this activity with sufficient instruction
4 - Have never done this, or not a skill of mine
(for volunteers under age 18 – please fill out this form and the Liability Release Form)
Name of volunteer: ___________________________________________________
I hereby give permission for my child to serve in the Disaster Response project coordinated by the West
Virginia Ministry of Advocacy and Workcamps on the following date(s)_________. In the event of an
emergency during the duration of the trip, I hereby give consent to a licensed physician to hospitalize,
secure proper treatment, anesthesia and/or surgery for my child named above.
I understand that I am responsible for his/her medical insurance and will not hold West Virginia Ministry of
Advocacy and Workcamps, Inc., liable for any injury or damage to my child while engaged in the disaster
Parent/Guardian Signature:
Home Telephone: _________________ Work Telephone: ___________________
Your relationship to participant: ____________________________
Does your child have any physical limitation that might affect his/her work?
Special needs if any:
Volunteer Signature: __________________________________________________
Date: ____________