Parent/Guardian Name If Under 18 Years Old
Parent/Guardian E-Signature if Under 18 Years Old
By e-signing below and submitting this application I affirm that the facts set forth in it are true and complete. I give my consent to the above mentioned minor to volunteer with ICNA Relief USA Programs Inc. I also give my consent to ICNA Relief USA Programs Inc. to add my information to the online database for future use. I understand that if accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me or the above mentioned minor on this application may result in immediate dismissal.
Emergency Contact Info
Liability Waiver and Release of Information
By E-Signing below you acknowledged and agreed to the following:
1) HNF Relief USA, HNF, or any other partner agencies are not liable and that you will not hold them liable in any accident or injury that you may incur while volunteering for HNF Relief USA Programs.
2) I, the Volunteer, release and forever discharge and hold harmless HNF Relief and its successors from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the volunteer services I provide to HNF Relief. I understand and acknowledge that this Release discharges HNF Relief from any liability or claim that I may have against HNF Relief with respect to bodily injury, personal injury, illness, death, or property damage that may result from the volunteer services I provide to HNF Relief or occurring while I am providing volunteer services.
3) I agree not to directly or indirectly seek, receive or accept any payment, reimbursement or other compensation whatsoever for your service as a volunteer or for any other goods or services provided by HNF Relief. This means, among other things, that you will not accept payments from a community member, patient, third party payer or any other source. You understand that you will be serving as an unpaid volunteer with HNF Relief, that you are not an agent or employee of HNF Relief, and that you have no power or authority to bind or obligate HNF Relief.
4) Insurance: Further I understand that HNF Relief does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance.
5) As a volunteer, I hereby expressly assume risk of injury, harm, or loss of property from any activities performed while volunteering and release HNF Relief from all liability.
6) As a volunteer, I hereby expressly assume risk of getting sick and/or infected with the Corona Virus from any activities performed while volunteering and release HNF Relief from all liability.
7) Photographic Release: I grant and convey to HNF Relief all right, title, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by HNF Relief in connection with my providing volunteer services to HNF Relief.
8) I am not experiencing at this time: fever, sore throat, cough, stuffy nose, or any other type of symptoms related to COVID-19.
9) I have not been in contact with anyone exhibiting any such symptoms, as mentioned in clause 7 above, within the last 14 days.
10) I have not traveled to any of the countries considered to be Level 1, 2, or 3 within the last month. Nor have I been in contact with anyone who has traveled to these countries.
Agreement and Signature
By e-signing below and submitting this application I affirm that the facts set forth in it are true and complete. I give my consent to HNF Relief USA Programs Inc. to add my information to the online database for future use.
It is the policy of this organization to provide equal opportunities regardless of race, color, religion, national origin, gender, age, or disability.