Test

* Your First and Last Name
* Over age 18? YesNo
If no, give age:
* Street Address
Apt
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* State
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Home Phone
* Cell Phone
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* Your Email
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How did you hear about us?

Medical Release

is authorized, if I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state in which he/she practices, during the duration of my volunteer time at Matthew 25 in Cedar Rapids, Iowa.

Physician
Physician phone
Medical Insurance Provider
Insurance phone
Policy Number
Group Number
Allergies
Medications
* In case of emergency, contact Name
* Relationship
* Address
* Phone:

Volunteer Skills/Experiences

Experience with Children A LotSomeLittleNone
Experience with teenagers A LotSomeLittleNone
Experience with gardening or farming A LotSomeLittleNone
Experience with with manual labor (lifting, shoveling, etc.) A LotSomeLittleNone
Experience with with construction, carpentry, or landscape improvement A LotSomeLittleNone
Experience with power equipment (saws, sanders, etc.) A LotSomeLittleNone
Comments (Experience/Education related to Volunteer Skills & Interests)

Availability

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* Liability Release: I do hereby release, forever discharge and agree to forever hold harmless Matthew 25 and any related agency, and the directors, employees, volunteers, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned that occur while participating in activities sponsored by Matthew 25. Furthermore, I hereby assume all risk of said personal injury, sickness, death, damage and expense as a result of participation as above set forth. The undersigned further hereby agree to hold harmless and indemnify said organization, its directors, officers, employees and agents, for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

Matthew 25 may send me email communications about programs and activities.

Matthew 25 may use any photos and video taken of me during my participation in the organization’s sponsored activities in future publications and advertisements without charge.

I, the [applicant and/or parent] for this [type of form], warrant the truthfulness of the information provided in this application.

* Electronic Signature Please type your First and Last Name
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance on behalf of myself and/or my minor child.