Care 4 A Healthy Community Volunteer Form

Care 4 a Healthy IE - Volunteer Application
Contact Information:
Name
Address
City, State, Zip
Phone Number
Cell Number
E-mail Address
T-Shirt size, circle one: XS, S, M, L, XL, 2XL, 3XL, 4XL
 I certify that I am at least 18 years old. Volunteers under 18 years old are not permitted.
Do you have medical insurance?  Yes
 No
Please list any allergies: __________________________________________________________
Person to contact in case of an emergency:
Name
Phone Number
Cell Number
E-mail Address
Relationship
Availability:
Saturday, November 15, 2014
____ Shift #1: 5:00 a.m. – 12:00 p.m.
____ Shift #2: 11:00 a.m. - 6:00 p.m.
Sunday, November 16, 2014
____ Shift #1: 5:00 a.m. – 12:00 p.m.
____ Shift #2: 11:00 a.m. - 5:00 p.m.
Tell us which area you are interested in volunteering:
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____ GENERAL VOLUNTEER
Greeter, usher, provide participant information, assist participants with registration, crowd
control, restock supplies, material distribution, run errands, provide security, assist in directing
parking, assist with event set-up and shut down.
 Do you speak another language? Please list language(s): _______________________
 Are you comfortable interpreting medical terminology:  Yes  No
_____ PROFESSIONAL VOLUNTEER
 Physician  Dentist  Optometrist
**Click on below link to register
https://docs.google.com/forms/d/1lr--EAM1x9KBKhmUtBUMFdResTIWMXWygHVLCVyjvmg/viewform
For information on the Tzu Chi Foundation, click on the below link:
www.tzuchimedicalfoundation.org
_____ MEDICAL ASSISTANT
Intake assistance, screenings, prepare areas for new patients
 Do you speak another language? Please list language(s):
 Are you comfortable interpreting medical terminology:  Yes  No
_____ DENTAL ASSISTANT
Intake assistance, screenings, prepare areas for new patients
 Do you speak another language? Please list language(s):
 Are you comfortable interpreting medical terminology:  Yes  No
Agreement and Signature:
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand
that if I am accepted as a volunteer for Care for A Healthy I.E., any false statements, omissions, or
other misrepresentations made by me on this application may result in my immediate dismissal.
Publicity Authorization
By submitting this application, I give to Molina Healthcare, Inc., American Family Care, Inc. (Molina
Medical Group), Buddhist Tzu Chi Medical Foundation, and each of the aforementioned entities’
nominees, agents, and assigns, unrestricted and irrevocable permission to use, publish, and
republish for purposes of advertising, trade, or any other lawful use, information about me and
reproductions of my likeness (photographic or otherwise) and my voice, whether or not related to any
affiliation with the Molina Healthcare, American Family Care (Molina Medical Group), and Buddhist
Tzu Chi Medical Foundation, with or without my name.
Waiver and Release from Liability
BY CHECKING THE BOX BELOW, I AGREE TO INDEMNIFY AND HOLD HARMLESS MOLINA HEALTHCARE, INC.,
AMERICAN FAMILY CARE, INC. (MOLINA MEDICAL GROUP), BUDDHIST TZU CHI MEDICAL FOUNDATION AND EACH
OF THE AFOREMENTIONED ENTITIES’ SUBSIDIARIES, AFFILIATES, SUCCESSORS, ASSIGNS, OFFICERS,
DIRECTORS, EMPLOYEES, AGENTS, SHAREHOLDERS AND INSURANCE CARRIERS (COLLECTIVELY, THE
“RELEASED PARTIES”) FROM AND AGAINST ANY AND ALL INJURIES, LOSS, LIABILITY, DAMAGE, COST,
DEMAND, SUIT, ACTION, JUDGMENT OR EXPENSE WHATSOEVER (INCLUDING REASONABLE ATTORNEYS’ FEES
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AND COURT COSTS) (COLLECTIVELY REFERRED TO AS "LOSSES"), ARISING OUT OF OR IN CONNECTION WITH
MY PARTICIPATION IN CARE 4 A HEALTHY I.E. (THE “HEALTH FAIR”), WHETHER KNOWN OR UNKNOWN,
INCLUDING, WITHOUT LIMITATION, ANY INJURY, DISABILITY, LOSS OF LIFE OR DAMAGE TO PROPERTY, ARISING
OR RESULTING FROM, IN WHOLE OR IN PART, MY PARTICIPATION IN THE HEALTH FAIR UNLESS SUCH LOSS IS
SOLELY CAUSED BY THE NEGLIGENCE OR INTENTIONAL MISCONDUCT OF A RELEASED PARTY.
Severability
I further expressly acknowledge and agree that the foregoing publicity authorization and the waiver
and release from liability are intended to be as broad and inclusive as is permitted by the law of the
State of California. If any portion thereof is held invalid, I agree that the balance shall,
notwithstanding, continue in full legal force and effect.
Name:
Date:
Electronic Signature: 
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Submit