Sarasota Volunteer Time Sheet

Date:

DOB:

mm/dd/yyyy

Salutation:

First Name:

Last Name:

Employer:

Occupation (current or former):

Special Needs or Physical Limitation:

Seasonal Resident:

If yes, Arrival Month:

Departure Month:

Local Address:

City/State/Zip:

Home Phone:

Cell Phone:

Evening:

Email:

Local Emergency Contact:

Emergency Phone:

Are you currently affiliated with a disaster relief agency? If yes, which agency?

Skills, Services, Trainings (Please check all that apply)

MEDICAL

OFFICE SUPPORT

STRUCTURAL LABOR

SERVICES

EQUIPMENT

OTHER LANGUAGES

COMMUNICATIONS

Release of Liability Statement

I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless Friendship Volunteer Center and Senior Friendship Centers, Inc. as the coordinating agency, Sarasota County Government, State of Florida, the organizers, sponsors and supervisors of all disaster preparedness, response, mitigation and recovery activities from all liability for any and all risk of damage or bodily injury or death or property damage, including any injury or damage caused by negligence, in connection with any volunteer disaster effort in which I participate or which may arise from my participation in volunteer disaster efforts or from my presence on a Sarasota County site or in Sarasota County vehicles as part of said participation. I likewise hold harmless from liability any person or agency transporting me to or from any disaster preparedness, response, mitigation, recovery and relief activities. In addition, disaster relief officials have permission to utilize any photographs or videos taken of me for publicity or training purposes without compensation paid to me. I will abide by all safety instructions and information provided to me during disaster relief efforts. I understand and agree that failure to abide by such safety instructions and information may result in my immediate dismissal from the Disaster Volunteer Program, without recourse.

Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State of Florida, 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 no known physical or mental condition 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.

Signature

Parent or Guardian, if under 18