Washington Conference of Seventh-day Adventists

Federal Way | WA

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Rebuild a Community
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Disaster Response Community Rebuilding Volunteer Registration Form

 

Contact Information

Title:

Mr. Mrs. Ms. Miss

 First & Last Name:

 *

Age:

Email:

*

 Cell Phone:

Day Phone:

Evening Phone:

Street Address:

City:

State:

    Zip:

Home Church:

   

Emergency Contact:

Relationship:

    Phone:
   

Occupation:

Employer:

Business Address:

City:

State:

   Zip:
   
  Are you interested in participating in the 
Katrina Community Rebuilding Mission Trip?
Yes
No
  Are you interested in participating 
in other Disaster Response activities?
Yes
No

Describe your special skills 
and/or vocational 
or disaster training you have:

Describe any relevant 
experience you've had:

 

Are you currently affiliated 
with a disaster relief agency?
Yes       Name of Agency:
No

What further training 
would you like to receive?

Commitment:
I am concerned about the continued suffering taking place in the aftermath of Hurricane Katrina and am committed to participating in the next ACS-Washington Disaster Response Community Rebuilding Mission Trip.

 
Release of liability:
I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless Adventist Community Services Disaster Response, the organizers, sponsors and supervisors of all disaster preparedness, response and recovery activities from all liability for any and all risk of damage or bodily injury or death that may occur to me (including any injury caused by negligence), in connection with any volunteer disaster effort in which I participate. I likewise hold harmless from liability any person transporting me to or from any disaster relief activity. In addition, disaster relief officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. I will abide by all safety instructions and information provided to me during disaster relief efforts.
 
Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
 

I have not known physical or mental conditions that would impair my capability to participate fully, as intended or expected of me. I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as my own free act.

Electronic Signature:     Date:

Guardian's Electronic Signature 
(if under 18):                 Date:
  or
* indicates a required field.