Volunteer Application

Be at least 13 years of age
Be able to pass a background check
Agree to abide by our child protection policy
Submit a volunteer application

Name *

First

Last

Date of Birth: *

Age: *

SSN: *

Please answer all questions. All information is confidential & used for background checks only.

Street: *

City: *

Zip Code: *

E-mail *

Phone: *

Check any that apply: *

I am certified in CPR/1st aid
I know sign language
I want to be a trained medical person handling medical issues at the respite
I want to be a buddy to someone with a disability
I to be a buddy to someone without a disability
Other, I can:

Do you have a disability? *

If yes, please explain:

Do you have any special needs? If yes, please explain:

Have you had any experience with people who have special needs or their families? *

Would you be interested in being a buddy at your church for Sunday services? *

Give at least two character references of people who have known you at least 5 years, with names and phone numbers. *

By providing my name below I waive my right of access to this form and release all references from any liability for information provided in good faith. I have read and agree to abide by the UHW child protection policy. *

* Anyone volunteering who is under 18 years will need to have their parent or guardian sign the following Consent & Release form on their behalf.

Are you 18 years or older? *

Yes, I am 18 years or older
No, I am not 18 years or older

If no, please fill out the Consent & Release form below

In consideration of myself and/or the individual *

*Insert participants name above

In consideration of myself and/or the individual, __________________________, (the participant) being allowed to participate in Under His Wings Respite programs (hereafter “program”), and to engage in activities related to the program, I, on behalf of myself and the participant, do hereby waive, release and forever discharge Under His Wings Respite Care, the Collins United Methodist Church, and the West Hartland Methodist Church, their leaders, agents, employees, representatives and volunteers from any and all claims, suits, actions, damages, losses, liabilities, costs and expenses of any kind or nature whatsoever, incurred for injuries and/or damages to the participant and/or his/her property, including those caused by the negligent act or omission of any person or entity release, arising out of the participant’s enrollment and participation in the program. I understand that Under His Wings Respite, the Collins Methodist, and the West Hartland Methodist Church is providing this program as a ministry to the church and community, and that the persons involved in this program are not health care or child care professionals. I do not rely on any claim of expertise, professional training, or other otherwise qualified care in allowing the participant to participate in the program. In the event that I am not immediately available, should the participant suffer a serious or life-threatening injury for which emergency medical treatment may be necessary, I hereby authorize an appropriate adult staff member, designated by Under His Wings Respite, the Collins United Methodist Church and the West Hartland Methodist Church, to engage qualified medical personnel to initiate any necessary medical treatment or care. In the event of such an injury, it is understood that Under His Wings Respite, the Collins United Methodist Church and the West Hartland Methodist Church will use all reasonable efforts to notify me (or the emergency contact listed on the participant’s application), where practical, prior to initiating medical treatment for any such injury to the participant. Should neither party be available, an appropriate staff person will contact appropriate medical personnel to initiate the necessary medical treatment, and I hereby give permission to any such physician or other medical personnel to provide such medical treatment such individual deems medically appropriate. I agree to pay for all care provided as a result of Under His Wings Respite, the Collins United Methodist Church and/or the West Hartland’s Methodist Church’s decision. I understand that I have the right to review this Consent and Release form with counsel, and have had the opportunity to discuss and consult with the counsel prior to signing this form. I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS CONSENT AND RELEASE OF LIABILITY AND THAT BY SIGNING IT, I INTEND TO BE BOUND LEGALLY AND TO BIND THE PARTICIPANT, OUR RESPECTIVE HEIRS, EXECUTORS, ASSIGNS, AND SUCCESSORS. I give Under His Wings Respite, the Collins Methodist Church and the West Hartland Methodist Church permission to take and post pictures or videos of any individuals on their respective websites, their printed material, and anything else associated with this program. We reserve the right to modify all Under His Wings Respite forms without prior notice. *

By providing my name above I verify the terms of the Consent & Release Form.

Date: *

Volunteer Application

Volunteer Requirements

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