Volunteer Registration Form

NAME: ____________________________________________________________

ADDRESS: Street_______________________ e-mail_____________________

City___________________________ State _________Zip___________

        Phone_______________ Day _______________Evening _____________

First Time Volunteer: YES NO Age:_______

ORGANIZATION AFFILIATION/PLACE OF WORK- (Business, Church, Civic organization, School, etc.)________________________________________________________________________

IF UNDER 18 Years of age

Name of parent or guardian__________________________________________

Home phone_______________________ Work phone_____________________

Parental consent: My son or daughter has my consent to perform volunteer construction work with Hosanna Industries

Signature: __________________________________________________________

MEDICAL CONSENT (All ages fill out)

Hosanna Industries, Inc. has my permission to administer or have administered any medical attention necessary in the event of accident or injury.

Signature: ____________________________________________

In the event of an injury, volunteers must present their own medical insurance information to the doctor or medical service that will be treating you.

VERIFICATION OF MEDICAL COVERAGE (Hosanna Industries Volunteers must have medical insurance)

Insurance Carrier_________________________ID No___________________(at policyholder’s discretion)

 Date of your last tetanus shot? ___________(if more than 10 years have transpired since your last tetanus shot please get a booster before you visit with us)

SPECIAL MEDICAL CONSIDERATIONS________________________________________

SPECIAL CONSTRUCTION AND/OR OTHER SKILLS

________________________________________________________________________

**If you would like to Receive our Newsletter please contact Amy Ed at our office.

 PHOTO RELEASE: I, the undersigned, permit use of photos and/or video images portraying myself in publications promoting Hosanna Industries, Inc.

 Signature X____________________________________ Date______________

LIABILITY RELEASE(to be signed with Volunteer Coordinator or group leader)

I, (print full name)_____________________________________________hereby release Hosanna Industries, Inc. (as well as its successor(s) and assigns) from any and all claims for damages, whether to person or property, arising from any accidents or injuries, direct or indirect, including travel to and from the day’s activities, which are caused or arise from my participating/volunteering with Hosanna Industries, Inc. work project(s):

Signature X_________________________________________ Date______________

Witness X___________________________________________ Date______________