Volunteer Interest Form
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Personal Info
First and Last Name *
Date of Birth *
Email address *
Phone Number *
Address (Street) *
Address (City) *
Address (State) *
Address (Zip Code) *
Name of event *
Role or position *
Please share your interest in volunteering with Willed By Wellness. Include your interest in the role as well as relevant experience you have for the role you're interested in volunteering for. *
Please include 2-3 references (include at least 1 professional references; 1 volunteer reference). List name and best contact. Please make sure to alert your references ahead of time. *
Emergency Information
Emergency Contact Name (First and Last) *
Relationship *
Emergency Contact Phone Number *
Physician *
Preferred Hospital *
Health Insurance Company *
Allergies *
Emergency Medical Treatment *
_____ for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of Willed By Wellness LLC. Consent for emergency medical treatment authorizes Willed By Wellness LLC to secure and retain medical treatment and transportation if needed and release client records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. If you choose DO NOT consent you will be required to meet with a full-time staff member.
Publicity Agreement *
______ to and authorize the use and reproduction by Willed By Wellness LLC of any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Release and Indemnity Agreement for Volunteers

In recognition of the fact that I will be working in a volunteer capacity with Willed By Wellness LLC to be conducted either at the Willed By Wellness LLC facilities in Nashville, Tennessee, or at another location for a Willed By Wellness LLC related event, I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, do hereby release, absolve, indemnify and hold harmless Willed By Wellness LLC, its representatives, supervisors, directors, officers, employees, suppliers, corporate sponsors or any other volunteers from any damages, injuries, claims, suits or costs arising in any way out of the conduct of the activities of Willed By Wellness LLC, including any injury which may occur at the Willed By Wellness LLC facilities or in transit to or from the Willed By Wellness LLC facilities or related events, except such liability or claim of liability as may result from gross negligence on the part of Willed By Wellness LLC. I am executing this Release with a full understanding that Willed By Wellness LLC will involve my working directly with its staff, volunteers, and clients (current or potential).


TYPE NAME BELOW AS ACKNOWLEDGEMENT

Confidentiality Statement

I understand that all medical, social, referral, personal and financial information regarding the student(s) and his/her family, other staff members and volunteers as well as Willed By Wellness LLC mailing lists is strictly confidential. (See the volunteer manual for the full Confidentiality Policy.)


TYPE NAME BELOW AS ACKNOWLEDGEMENT

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