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2022 Registration Form: Disaster Relief - Mayfield, KY - Tornados
Thank you for your willingness to serve on a HHI Disaster Relief Team!  We expect this project to span multiple weeks, starting in January 2022 and running through February 2022.  We plan to deploy several teams to Mayfield, KY and will primarily focus on providing Disaster Relief to local Tornado Victims.  Please complete the below online registration form for each Volunteer interested in joining a Disaster Relief Team and an HHI Staff member will reach out to you shortly.  Should you have any questions about the project, please call our office at: 541.414.4426.  God bless!
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First & Last Name (e.g. John Smith) *
Phone Number (e.g. 541-123-4567) *
Email Address (e.g. johnsmith@gmail.com) *
Mailing Address (e.g. 123 Main Street, Medford OR 97504) *
Date of Birth (Please note: You must be 18 years of age or older to join HHI on this project.) *
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Have you had any COVID-19 symptoms in the last 14 days? (see https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) *
Do you agree to abide by Samaritan Purse's COVID-19 Requirements?  "COVID-19 Considerations: All staff and volunteers will strictly adhere to COVID-19 federal and local guidelines to ensure their safety and the safety of homeowners and residents. Non-local volunteers not returning to their own residence after serving for the day must provide proof of a negative COVID-19 test (administered by a provider) 72 hours prior to arrival. Please do not use an over the counter test. This must be presented to staff upon check-in at the site and will be required regardless of vaccination status. " *
Which week(s) are you willing to serve on this project?  Please select all that may apply. *
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Who should we contact in case of an emergency?  Please include their name AND phone number (e.g. Mary Jane (541) 111-1111). *
Gender *
Shirt Size *
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I understand that Helping Hands International is a nondenominational Christian organization, whose primary goal is to share the love of God through practical, hands on care.  I agree to adhere to the policies and procedures of Helping Hands International and represent them with integrity.   *
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ACKNOWLEDGEMENT OF RISK AND RELEASE OF LIABILITY                                                                                      I, the undersigned participant in the Outreach identified above, have been advised of the nature of the activities that may take place during the Outreach (including, but not limited to, building projects, medical work and misc. projects) and hereby represent that I am physically and mentally able to participate in those activities.      I understand that the activities to be engaged in during the Outreach may involve foreseeable and unforeseeable risks and hazardous activity which may be dangerous and may involve the risk of injury, possibly even severe injury or death. I hereby represent that I am voluntarily assuming the risk of any such injury and agree to release and hold Helping Hands International, Inc., its directors, officers, staff members, agents, and volunteer workers (hereafter collectively referred to as “HHI representatives”) free and harmless from any and all liability for injury, damage and/or loss, to my person or property, in connection with my travel to, attendance at and participation in the Outreach, including but not limited to any such injury, damage or loss that may arise as a result of the negligence of Helping Hands International, Inc. or the HHI representatives.  I further acknowledge a greater risk of contracting the COVID-19 virus as I participate with other volunteers.  I also hereby release Helping Hands International, Inc. and any HHI representatives, and agree to indemnify and hold them harmless from and against any and all liability for any actions, damages, causes of action, suits, costs, losses, expenses, claims, demands, and judgments, collectively known as “Losses and Claims”, which I, my spouse, family members, children, invitees, heirs, executors, administrators, successors, and assignees ever had, now have or hereafter can, shall or may have resulting from or arising in connection with my travel to, attendance at or participation in the Outreach.  I also agree to hold Helping Hands International, Inc. and any HHI representatives free and harmless from any and all liability to any other person or entity for personal injury or property damage arising as a result of my negligent or intentional conduct during my travel to, attendance at and participation in the Outreach, and agree to defend and indemnify Helping Hands International and any HHI representatives against any Losses and Claims arising as a result of such conduct.  I am aware that many of the outreach locations may have a Travel Warning or Travel Alert in effect, which increases the risk Involved. Current Warnings and Alerts are posted on the U.S. State Dept. web site at www.travel.state.gov.  In the event that I may need emergency medical treatment during my participation in the Outreach, Helping Hands International and the HHI representatives are hereby authorized on my behalf to arrange for any medical and hospital treatments as may be deemed advisable for my health and well being. I hereby consent to the performance of such medical treatment, anesthesia and surgery as, in the opinion of an attending physician, is deemed necessary.  I, the undersigned, have read the above Acknowledgment of Risks and Release of Liability and agree to its provisions. I am aware that this is a release of liability and a binding contract which shall be governed by Oregon law and that this Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Oregon. If any portion of this Agreement is held to be invalid, it is agreed that the remainder shall, notwithstanding, continue in full force and effect. *
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Digital Signature Date *
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