Waiver and Release Form

Your acceptance of a volunteer assignment must carry with it your understanding that the assignment is offered pending final clearances and may be terminated at any time with or without cause, or changed at any time by Glocal Community Partners. By accepting a volunteer assignment, you also agree to the following:

Name

Waiver and Release: I understand and acknowledge that this Release discharges and holds harmless Glocal Community Partners, its employees, agents, sponsors, donors, volunteers, Board members and its successors and assigns from any liability or claim that I may have against Glocal Community Partners brought by me or by any party on my behalf with respect to bodily injury, personal injury, illness, death, or property damage that may result from the service I provide to Glocal Community Partners or occurring while I am providing volunteer services.

Agree Disagree

Assumption of Risk: I understand that the services I provide to Glocal Community Partners may include activities that may be hazardous to me. As a volunteer, I hereby expressly assume the risk of injury or harm from my activities with Glocal Community Partners and release Glocal Community Partners from all liability for injury, illness, death, or property damage resulting from the services I provide as a volunteer or occurring while I am providing volunteer services. I acknowledge that Glocal Community Partners asks all volunteers to use universal health precautions when interacting with refugees.

Agree Disagree

Insurance: Further I understand that Glocal Community Partners does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any nature in the event of my injury, illness, death, or damage to my property. I expressly waive any such claim for compensation or liability on the part of Glocal Community Partners beyond what may be offered freely by Glocal Community Partners in the event of such injury or medical expenses incurred by me.

Agree Disagree

Confidentiality: I agree to hold in confidence identifying information regarding refugees such as names, places of residence, government issued ID numbers, photos, personal information, etc. Identifying information may only be released with the consent of refugees.

Agree Disagree

Hands Free Driving: I agree to drive with hands on the wheel anytime that I am involved in driving for a Glocal Event/Program with a person/family who have come as refugees. To use a cell phone while driving, I will only do so with a hands-free device.

Agree Disagree

Permission to Use Photograph: I grant Glocal Community Partners the right to take pictures of me and my property in connection with any Glocal Program or activity. I agree that Glocal Community Partners may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I release, discharge and agree to hold Glocal Community Partners harmless from and against any and all liability in connection with the use of such media pursuant to this release. *

Agree Disagree

Other: I understand and agree that Glocal Community Partners is relying on my promise to volunteer as scheduled. I agree to contact the appropriate Glocal Community Partners staff member if conflicts arise in which I cannot fulfill my volunteer obligations.

Agree Disagree

By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily. I certify that the above information is correct. I authorize the named references to release information to Glocal Community Partners.

Signature

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Waiver and Release Form

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