Church/Organization Affiliation:

I am voluntarily participating in CommunityWorx activities and verify this statement by placing my initials below:

 I acknowledge that cutting, splitting, stacking, and other activities involved with the Firewood Program can be hazardous.  I am participating knowing the potential danger involved. I AGREE TO INFORM COORDINATORS IF I DO NOT FEEL QUALIFIED OR SAFE TO DO AN ACTIVITY.  Use of safety equipment is available and recommended including the following: 

Chainsaws: chaps, safety glasses, gloves, ear plugs, and helmets.   

Wood splitters: safety glasses, gloves, ear plugs, and helmets.  

Stacking wood: gloves and if chainsaws or wood splitters are in use where you are working, safety glasses, gloves, ear plugs.  

I agree to assume all risks, whether I choose to use provided safety equipment or not, and verify this statement by placing my initials below:

I agree to the following behavioral expectations:

I will treat other volunteers and CommunityWorx clients with respect.  I understand that I can share my beliefs if they are willing to listen; however, completion of projects will not depend on the client’s willingness to listen.

I will maintain healthy personal boundaries while at a client’s home, including not entering any areas of the home without the permission from the client.  I will be aware of the potential for clients to perceive a power differential between myself and them and not take advantage of this relationship to further personal, political, or business interests.  

I will hold confidential any personal information obtained about clients, including the location of the site.

I will not accept monetary or material gifts for services rendered.  If clients would like to show appreciation in this manner, please suggest that they make a donation to CommunityWorx to help other families.

I will be sensitive when speaking about the conditions of a site so that any comments are not misinterpreted or perceived by the client as being judgmental. 

I agree to the above behavioral expectations and verify this statement by placing my initials below:

I give permission for photographs/video taken of me during CommunityWorx events to be used for promotional purposes and verify this statement by placing my initials below:

I hereby agree that I, my assignees, heirs, distributes, guardians and legal representatives will not make a claim against, sue, or attach any property of CommunityWorx, its directors, officers, agents, employees, volunteers, partners and affiliates, the suppliers of any of the tools, equipment, facilities, or property that I will use in these activities, or the Alliance for Green Heat, for injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, contractor, coordinator, volunteer, or other participants in CommunityWorx activities.  I hereby release CommunityWorx, its directors, officers, agents, employees, volunteers, partners and affiliates, the suppliers of any of the tools, equipment, facilities and property and the Alliance for Green Heat from any and all liability including but not limited to actions, claims, or demands that I, my assignees, heirs, distributes, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in CommunityWorx activities.

I agree to the above ASSUMPTION OF RISK AND RELEASE OF LIABILITY and verify this statement by placing my initials below:

In case of an accident, illness, or emergency, I authorize the Leader for my site to seek medical aid on my behalf and to contact my emergency contact. I verify this statement by placing my initials below:

SIGNATURE REQUIRED BELOW (VOLUNTEER):

I have carefully read this ASSUMPTION OF RISK and RELEASE OF LIABILITY, and fully understand its contents.  I am aware that it is a release of liability and a contract between myself and CommunityWorx.  I am signing of my own free will.

I agree to the above ASSUMPTION OF RISK AND RELEASE OF LIABILITY and verify this statement by placing my full name below as my signature:

GUARDIAN SIGNATURE REQUIRED BELOW (FOR MINOR VOLUNTEER DELIVERING FIREWOOD) (List "N/A" if not applicable):

I have carefully read this ASSUMPTION OF RISK and RELEASE OF LIABILITY, and fully understand its contents.  I am aware that it is a release of liability and a contract between myself and CommunityWorx.  I am signing of my own free will.

As the legal guardian of the above listed minor child, I agree to the above ASSUMPTION OF RISK AND RELEASE OF LIABILITY and verify this statement by placing my full name below as my signature: