Volunteer Contact Information

Preferred Name (if any)
Pronouns*
If 'Other' was checked, fill in pronoun
Date of Birth (mm/dd/yyyy)*
Gender**
Languages Spoken Fluently *
If other language was checked, please list what is spoken.
Country*
Email*
Confirm Email*
Cell Phone*
Home Phone Number
Race/Ethnicity (Optional) Check all that apply
Current Employer (Optional)
Highest Education Level
Other organizations where you have volunteered?
Any applicable certifications (CPR/First Aid/Educator)?
How did you hear about us?*
Hours and Days Available*
What volunteer activities are you interested in?*

References

Must provide two references, relatives not permitted. References will be contacted by email.

Reference Name (#1)*
Reference Email (#1)*
Reference Relationship (#1)*
Reference Name (#2)*
Reference Email (#2)*
Reference Relationship (#2)*

Emergency Contact Information

Emergency Contact Name*
Relationship*
Phone*
Emergency Contact #2*
Emergency Contact #2 Relationship*
Emergency Contact #2 Phone*

Emergency Care

If I, the volunteer, am unable to consent or make medical decisions in an emergency, I authorize Northwest Association for Blind Athletes to seek medical care on my behalf. Including but not limited to OTC medication, emergency medication, diagnostic procedures, anesthesia, surgical and medical treatment and blood transfusions, by medical providers, hospitals or their authorized designees, as may in their professional judgment be necessary to provide for the medical, surgical or emergency care.

Consent to Emergency Care*

Allergies & Dietary Restrictions

Please be as specific as possible. If not applicable, please write N/A.

Food Allergies (Please List)*
List Special Dietary Needs*
List any Environmental Allergies*
Allergic to any Insect Bites or Stings*
Allergic to any Medications*
Latex Allergy*
Has a doctor ever limited your participation in sports or physical activity?*
Do you, the applicant have any activity restrictions?*

Health History

The purpose of requesting health history information is to provide the safest and most successful environment for you while participating in our programs and services. We ask that you take your time and answer all questions honestly.

 

Have you ever been diagnosed or experienced any of the following conditions? if yes is checked, we will ask you to describe below.

If you have been diagnosed or experienced any of the above conditions, please describe: *

Emergency Medical Medication/Support

Other Emergency Medical Medication/Support that is NOT listed?*
List any other ongoing or past medical conditions, surgeries or infections:*

Epilepsy and/or Seizure History

If applicable, list seizure type:
If Applicable Date of Last Seizure:

Mental Health History

Please describe any additional mental health concerns NWABA should know about:*

Volunteer Release & Waiver of Liability and Indemnity Agreement

Volunteer Release & Waiver of Liability and Indemnity Agreement

 

PLEASE READ THIS RELEASE AND WAIVER CAREFULLY AND IN ITS ENTIRETY. THIS RELEASE AND WAIVER AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS RELEASE AND WAIVER, YOU ARE RELEASING NORTHWEST ASSOCIATION FOR BLIND ATHLETES (“NWABA”) FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR.  

 

Acknowledgment of Volunteer Status

 

As a volunteer, I acknowledge and agree I am not an employee of Northwest Association for Blind Athletes. I acknowledge and agree that I will not receive any compensation or benefit for my participation in volunteer programs, nor will I be eligible for any coverage under the Workers’ Compensation laws.

 

Assumption of Risk

 

I acknowledge and agree that any use of NWABA facilities, services, equipment, and premises (“Facilities”) and any participation in NWABA programs and activities, including virtual programs and activities (“Programs”), comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease.

 

I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Volunteer Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this Release and Waiver.

 

Waiver, Release, Indemnification, & Covenant Not to Sue

 

In consideration of the use of Facilities and participation in Volunteer Programs, I, the undersigned, agree that NWABA, along with its affiliates, predecessors, successors, officers, directors, agents, consultants, employees, volunteers, insurers, representatives, and assigns (collectively, “Releasees”) will not be liable for any personal injury, property damage, disability, accident, death, loss, sickness, or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring, including, but not limited to, the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Volunteer Programs.

 

I further agree, on behalf of myself and any and all legal successors, assigns, and proxies, to release and HEREBY DO RELEASE, WAIVE, AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases, or accidents of any kind, arising out of or in any way related to the use of Facilities or participation in Volunteer Programs, whether that participation is supervised or unsupervised, and however the injury or damage occurs, including, but not limited to, the negligence of Releasees. This Release and Waiver does not extend to claims for gross negligence, intentional or reckless conduct, or any other liabilities that applicable law does not permit to be excluded by this Release and Waiver.  

 

I also agree not to sue or make a claim against the Releasees for personal injury, property damage, disability, death, sickness, diseases, or accidents of any kind, arising out of or in any way related to the use of Facilities or participation in Programs. 

 

In further consideration of the use of Facilities and participation in Volunteer Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releases from any and all causes of action, claims, demands, losses, suits, judgments, settlements, awards, interest, penalties, liabilities, or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Volunteer Programs by myself, my family members, dependents, or guests, including any minors. In accordance with these promises, I will reimburse the Releasees for any damages, reasonable settlements, and defense costs, including attorneys’ fees, that they incur because of any such claims made against them. I agree that in the event of my death or disability, the terms of this Release and Waiver, including the indemnification obligations, will be binding on my estate, and my personal representative, executor, administrator, or guardian will be obligated to respect and enforce them. 

 

Use of My Likeness

 

I hereby grant NWABA and its assigns permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I further license NWABA and its assigns the right to use photos or likenesses of me for the purposes described in this authorization.

 

I understand and agree that all photos will become the property of NWABA and will not be returned. I hereby irrevocably authorize NWABA to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising out of or related to the use of the photo. This authorization specifically includes the right to take and record photographs or likenesses of me, and the right to use my name and any such photographs or likeness for the purposes described in this authorization. 

 

Severability and Termination

 

I expressly agree that this Release is intended to be as broad and inclusive as permitted by the law in the state the Volunteer programs take place. Any portion of this Release deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining portions of this Release, or this Release as a whole, to the full extent authorized by law. 

 

I authorize and give consent for Northwest Association for Blind Athletes to obtain information regarding myself. This includes the following:                         

  • Applicant Verification – full SSN trace
  • County Criminal Search
  • Multi-Court Jurisdictional Search
  • Federal Criminal Search
  • Nationwide Sex Offender Search
  • Global Watch Search

I, the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm, or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization’s guidelines. A criminal report may be obtained at any time after receipt of your authorization, and, if you are approved, throughout your volunteering.

 

I certify that I have reviewed all of the above terms of this Release AND WAIVER, and, by signing below, I hereby accept and agree to the terms of this Release AND WAIVER in their entirety. I UNDERSTAND THIS IS A CONTRACT THAT AFFECTS MY LEGAL RIGHTS AND I SIGN IT OF MY OWN FREE WILL.    

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