Pursuing freedom & healing from addiction. At all costs.

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Your information


Required fields are marked with an asterisk (*).
First Name *
Last Name *
Mobile Phone

For example, 123-456-7890
SMS/text messaging: By providing your mobile number and checking the box below, Addiction Prevention Coalition will be allowed to send you SMS (text) messages relating to their volunteer activities. To opt-out, reply STOP to any SMS message OR return to this form and uncheck the box.
When is your birthday? *

A valid date as MM/DD/YYYY (for example: 11/30/2015)
Are you volunteering with an organization?
What is your shirt size?
Do you have any specific areas of interest that you would like to be involved in?
What days are you available?






What times are you available?


Name of Emergency Contact *
Phone Number of Emergency Contact *
Relationship to Emergency Contact *
Is there anything the Addiction Prevention Coalition should know to help make your experience as a volunteer great?

Waiver

Volunteer Liability Waiver and Agreement

This document explains possible risks of volunteering and includes liability waivers, consents, and other legal agreements.

By signing below, I, the volunteer (or volunteer’s legal guardian), acknowledge that entry into this agreement (“Agreement”) is in consideration of my participation as a volunteer, and confirm my understanding and agreement to the following:

Policies and Safety Rules
I will comply with Addiction Prevention Coalition’s volunteer policies, safety rules, conduct expectations, and other directions. I understand that Addiction Prevention Coalition does not tolerate bullying, harassment, threatening behavior, or violence of any kind. I understand that noncompliance may result in termination of my volunteer status.

Volunteer Not an Employee
I understand that (a) I am not an employee of Addiction Prevention Coalition, (b) I will not be paid for my participation, and (c) I am not covered by or eligible for any Addiction Prevention Coalition insurance, health care, worker’s compensation, or other benefits. I understand that Addiction Prevention Coalition may terminate my volunteer status at any time, for any or no reason.

Risks Associated with Volunteering
Volunteering for Addiction Prevention Coalition has risks. These risks may arise in a variety of ways. They include, without limitation: my lifting heavy objects or otherwise exerting myself, handling glass and other potentially dangerous materials, using hot or sharp objects or other tools, being exposed to dust, loud noises, and interacting with and being in the presence of other volunteers, visitors, and other people. I understand that these risks include risks of injury, illness, death, and property damage or loss, and that they may arise from my own actions or from the actions of others at or near Addiction Prevention Coalition facilities or encountered when traveling for Addiction Prevention Coalition activities offsite. I also understand that even if Addiction Prevention Coalition, I, and other persons present at Addiction Prevention Coalition facilities follow all health and safety protocols, I may still be exposed to COVID-19 or other infectious diseases.

Awareness and Assumption of Risk
I understand the information above and confirm and acknowledge that these are risks associated with volunteering. With such information and awareness, and with the recognition that other factors may create additional such risks, I knowingly, freely, and voluntarily: (a) sign up to volunteer for Addiction Prevention Coalition; (b) engage in volunteer activities; and (c) assume and accept the risks of all injury, death, property damage or loss, financial obligation, loss of privacy, loss of reputation, and all other injuries and other consequences, whether known or unknown, whether foreseen or unforeseeable, and whether incurred at Addiction Prevention Coalition facilities or elsewhere, that may result, directly or indirectly, from my presence at Addiction Prevention Coalition facilities or participation as a Addiction Prevention Coalition volunteer, regardless of the cause.

Waiver and Release of Claims
I waive and release Addiction Prevention Coalition and its directors, officers, agents, employees, volunteers, and affiliates (collectively, “Addiction Prevention Coalition Parties”) from any and all liability, claims, costs, and expenses of any kind and of whatever nature which I or my heirs, next of kin, or legal representatives may have or which may later accrue, caused by or arising directly or indirectly from my presence at Addiction Prevention Coalition facilities or participation in Addiction Prevention Coalition activities. This release and waiver include, in each such case, all claims in respect of the risks noted above, known and unknown, foreseen and unforeseeable, regardless of the cause or whether such claims arise from tort, contract, or otherwise, and even if caused by negligence, whether passive or active. I will not sue any of the Addiction Prevention Coalition Parties on the basis of these waived and released claims.

Disclosure of Medical Conditions
I understand that I am solely responsible for knowing my own physical condition and making my own decision about volunteering. I have disclosed all medications and conditions relevant to my participation to my supervisor or other staff at Addiction Prevention Coalition, including chronic conditions such as asthma, allergies, seizures, or diabetes. I understand that Addiction Prevention Coalition needs such information because some medication side effects, or medical conditions could affect my safety or that of others at Addiction Prevention Coalition. I consent to Addiction Prevention Coalition sharing this information with health professionals or first responders should I become ill or injured while at Addiction Prevention Coalition facilities.

Medical Care Consent and Waiver
I authorize Addiction Prevention Coalition to provide me with first aid and to arrange medical assistance, transportation, and emergency medical services for me if I get hurt while volunteering. I understand that Addiction Prevention Coalition is not obligated to provide this care. I also understand that I am solely responsible for any costs related to my medical treatment and transport, and that Addiction Prevention Coalition does not provide health, medical, disability, or other insurance coverage for me.

Confidentiality
I may have access to Addiction Prevention Coalition’s confidential information. At all times during and after my participation, I agree to hold any such confidential information in confidence and not disclose or use it except as Addiction Prevention Coalition expressly authorizes.

Assignment of Work Product
I grant full rights to Addiction Prevention Coalition in any reports, brochures, website content, photos, images, videos, or other materials or works I may create in the course of volunteer activities, and any intellectual property rights in or derivatives of such materials.

Use by Addiction Prevention Coalition of My Name and Image
I understand that Addiction Prevention Coalition may take photos or videos of me. I consent to use by Addiction Prevention Coalition of my image, voice, name, and story, and of images of any works I may create as a volunteer (collectively, “Materials”), in Addiction Prevention Coalition’s digital and print promotional, fundraising, educational, and other communications. Addiction Prevention Coalition may use the Materials without obtaining my approval or paying me for such use. I grant Addiction Prevention Coalition all copyrights in and waive any legal claims relating to the Materials, including those relating to copyright, rights of publicity or privacy, or defamation, or arising from any distortion, blurring, or alteration that may occur in the making, editing, or use of the Materials.

General Provisions
I understand that this Agreement will be binding for so long as I am a volunteer at Addiction Prevention Coalition. This Agreement will run in favor of, and may be enforced by, each of the Addiction Prevention Coalition Parties, and will bind my heirs, next of kin, and legal representatives. This Agreement will be binding to the fullest extent permitted by law. If any provision of this Agreement is found to be unenforceable, the other terms remain effective.

• I affirm that I am of legal age and able to sign on my own behalf and am freely signing this Agreement. I have read this Agreement and fully understand that by signing this Agreement, I am giving up legal rights and remedies that may be available to me and to other persons.

• I affirm that I am the parent or legal guardian of the participant and am freely signing this document on their behalf. I certify that I have the authority to sign on behalf of the participant and to make decisions for the participant regarding volunteering. I also waive and release Addiction Prevention Coalition Parties from any and all liability, claims, costs, and damages of any kind which I may have resulting or arising directly or indirectly from the participant’s participation in volunteering. I have read this Agreement and fully understand that by signing this Agreement, I am giving up legal rights and remedies that may be available to the participant, to me, and to other persons.