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Carbon County Montana

info@co.carbon.mt.us

17 W. 11th St, PO Box 887, Red Lodge, MT, 59068, US

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1. CONTACT INFORMATION

Full Name

Birth Date

Full Address

Emergency Contact

2. AVAILABILITY

Would you like to provide information to help us place you in a position that fits your skills and abilities?

Where are you willing/able to volunteer?

What days of the week are you able to volunteer?

What time blocks are you generally available?

Can you provide your own transportation while volunteering?

Do you have any medical conditions or physical limitations that might limit you if asked to volunteer?

3. SKILLS: Please check all that apply

MEDICAL

COMMUNICATIONS

Language other than English

OFFICE SUPPORT

SERVICES

STRUCTURAL

TRANSPORTATION

LABOR

EQUIPMENT

4. RELEASE OF LIABILITY STATEMENT

I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless this locally sponsored Volunteer Center, Carbon County, State of Montana, 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 of Montana, 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

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