Volunteer Liability Release Form

I would like to volunteer for the Broome County Council of Churches Inc. I understand that I am responsible for my own medical insurance and will not hold Broome County Council of Churches Inc. liable for any injury or damage to myself, or my property, while volunteering at the Broome County Council of Churches.

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Volunteer Liability Release Form

Please fill out online or print out an application form here

Volunteer Liability Release Form

Title
Volunteer first name*
Volunteer last name*
Phone*
Email
Address*
Street Address City State / Province / Region ZIP / Postal Code
Program*
Date of Birth
Date Format: MM slash DD slash YYYY
Group Affiliation
Volunteer's Signature*
By typing my name above I am providing my electronic signature which represents and is equal to my physically written signature
Today's Date
Date Format: MM slash DD slash YYYY
MAY WE USE/TAKEPHOTOGRAPHS AND/OR VIDEO THAT WE MAY HAVE OF YOU WHILE YOU WERE VOLUNTEERING FOR THE BROOME COUNTY COUNCIL OF CHURCHES FOR PROMOTIONAL PURPOSES?*
- Yes
- No
Emergency Contact Information
Any Known Allergies
Emergency Contact Name*
Relationship*
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code
Please list any medical concerns that we should know about*
Parental Consent (If participant is under the age of 18)
I give permission for my child to serve as a volunteer for the Broome County Council of Churches. In the event my child requires any medical care while serving with the Council, and I am unavailable,
Parent/Guardian who is authorized to consent to medical care of this minor
First Last
authorizes any doctor or hospital to provide such treatment as that individual determines would be appropriate to care for the condition with which the minor presents to said doctor or hospital. The Broome County Council of Churches shall not be liable for any health care, which its representative authorizes,as long as such care is recommended by the hospital or the doctor.I understand that I am responsible for this minor’s own medical insurance and will not hold the Broome County Council of Churches Inc., or any of its agents, liable for any injury or damage to this minor while volunteering for the Council.
Name of Parent/Guadian
Relationship to Minor
Primary Phone
Other Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Insurance Company
Policy Number
Does this minor have any physical limitations that we need to be aware of?
Please list any medical concerns that we should know about
I GIVE PERMISSION FOR ABOVE NAMED MINOR TO USE POWER DRILLS (CIRCLE ONE)*
- Yes
- No
Parent/Guardian Singature
By typing my name above I am providing my electronic signature which represents and is equal to my physically written signature
Date
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Broome County Council of Churches Inc.

3 Otseningo Street
Binghamton, NY 13903
607.724.9130
mail@broomecouncil.net

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Volunteer Liability Release Form

Volunteer Liability Release Form

Volunteer Liability Release Form

Volunteer Liability Release Form

Emergency Contact Information

Parental Consent (If participant is under the age of 18)

Broome County Council of Churches Inc.

Quick Links

Stats

Adults Found Employment Through CHOW Works Job Training

Older Adults received services to remain independent & healthy & maintain quality of life!

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