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2. Program
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone Number
16. Phone Number
18. Email
20. Date of Birth
21. Age
22. Male or Female
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24. Emergency Contact
25. Phone #
27. Relationship
29. Are there any medical conditions or allergies that we need to be made aware of?

31. Required by the Town of Benson for all volunteers. Please read carefully! This is a legal document that affects your legal rights.

    I want to participate in the volunteer activities for the Town of Benson, henceforth referred to as the Town. As a Town Volunteer, I freely, voluntarily, and without duress, execute this Release under the following terms:

    1. Assumption of risk. I understand that my work for Town may include activities that are hazardous and/or physically strenuous, and I may be exposed to personal injury or damage to my property as a result of my activities, the activities of other persons, or the conditions under which my services are performed while participating in Town volunteering. In recognition of the foregoing, I hereby agree to the following:

    • I will follow all instructions provided by the Town, its employees, or volunteer coordinator(s).

    • I will only use equipment that I know how to operate and use safely.

    • I will not undertake any activity for which I do not feel sufficiently prepared or able, and until I have received instructions.

    • I will take all reasonable precautions to avoid injury to myself and to others and damage to property.

    • Finally, I agree to assume the risk of injury or harm and release the Town, its officers, directors, employees, agents, successors and assigns, and other Town volunteers from all liability for injury, illness, death, or property damage arising from my work as a Volunteer.

    2. Waiver and Release. For and in consideration of my participation as a volunteer, I hereby release and forever discharge and agree to indemnify and hold harmless the Town, its officers, directors, employees, agents, successors and assigns, and any other Town volunteers from any and all claims, liabilities, losses, damages, costs and expenses resulting from injury or death of any person or persons property damage or that may arise out of my work or participation as Volunteer.  I understand that this release discharges the above entities from any liability that may result from my work whether caused by the negligence of the Town, its officers, directors, employees, or agents or otherwise.

    3. Medical treatment. I release and discharge the Town from any claim that arises or may arise due to any first aid, medical treatment, or service rendered to me.

    4. Insurance. The Town does not have responsibility for providing any health, medical or disability insurance coverage for me. Volunteers are encouraged to have medical/health insurance. I understand that if I drive my personal vehicle for Town business while volunteering, I must have a valid driver’s license and proof of auto insurance.

    5. Photographic release. I grant the Town the right to use photographic images and video or audio recordings of me that are made by the Town or others during my volunteer work for the Town.

    6. Duration of Release. My agreement to the terms in this Release & Waiver applies as long as I volunteer for the Town.

    7. Background Check. I authorize the Town of Benson and its agents and representatives to conduct a review of my background and to obtain a consumer credit report and/or an investigative consumer credit report and any other information necessary for the purpose of volunteering with the Town of Benson. I also agree to complete all additional authorization forms need to conduct said background checks.

    8. Other. I agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of North Carolina and that this Release is governed by and will be interpreted according to the laws of the State of North Carolina. I understand that should any part of this Release be ruled invalid by a court, the other parts will remain valid and continue to be in effect.

    I certify that I am at least eighteen (18) years of age.

33. I certify I have read and agree to the terms above.

    1. I accept
    2. I do not accept
34. Date
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36. 1. Receive an email copy of this form.
37. Email address

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38. Submit

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