Old Southern Home

Volunteer Name*

First Last

Date of Birth*

Volunteer is an*

If entrant is under 18, a parent or legal guardian must sign.

Adult
Minor

Parent/Guardian Name*

Also used as emergency contact.

First Last

Emergency Contact*

First Last

Emergency Contact Phone*

Email*

By providing your email address you agree to communications from the Kenmore Heritage Society.

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Position

Any special talents or skills you have that you feel would benefit our organization?

What type of volunteer work would you like to do?*

Events
Program
Fundraising
Communication
Other

Please indicate days available:

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Times Available

Any physical limitations?

I understand my involvement with Kenmore Heritage Society may include coverage in the media. I approve use of my likeness, voice, photograph, words and any other creative work without payment or consideration by the media or the Kenmore Heritage Society.*

I agree
I do not agree (please clarify below)

Waiver of Liability*

In consideration of the Kenmore Heritage Society allowing me (my child/children) to participate in the Kenmore Heritage Society volunteer program, and being aware of the possible injuries that could occur as a result of that participation, I on behalf of myself (my minor child/children) release the Kenmore Heritage Society officials, employees, agents, instructors from any and all injuries and damages whatsoever arising from participation in the event. I, my heirs and representatives, agree to indemnify, save and hold harmless the Kenmore Heritage Society, its officials, employees and agents from any and all claims made by me (my child/ children) or my insurer for injuries or damages related to this event. I certify that all information provided on this application and during the interview process is true and complete. I understand that falsification or significant omissions of any information may be considered justification for non-acceptance or dismissal if discovered at a later date and that appointment to a volunteer position may be contingent upon the completion and review of a criminal background check. Please note that by signing below, you are affirming that all answers given in this document are true and correct to the best of your knowledge.

I agree

Agreement*

As a volunteer of our organization I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward.

I agree

Tell us a bit about why you want to work with us.*

Signature of Applicant or Guardian

Phone

This field is for validation purposes and should be left unchanged.

Historic Kenmore

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