VAC Application & COVID 19 Waiver

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

First Name *

Last Name *

Local Union *

If "Other" selected above, please provide information below.

Are you Retired *

YES

Address: *

City *

State *

Zip Code *

County (not country) *

Phone Number *

Social Security # (Last 4 Digits)

If 17 years of age or under please provide age ONLY

Age Group *

0-5 years old

6-10 years old

11-17 years old

18 & up

I wish to participate in the following activities (check all that apply) *

Participate in Political Activities sponsored by District Council 16

Participate in shop steward training and accept appointment when called upon

Participate in demonstrations, pickets, CORE classes and other organizing activities

Participate in District Council 16 sponsored charities raising money for sponsored charities

Participate through the donation of labor in District Council 16 sponsored charity projects

Participate in District Council 16 sponsored events of the Retiree Activist Committee

Participate in District Council 16 sponsored events of the Women’s Growth & Action Committee

Required

Release of Liability, Waiver of Claims, Assumption of Risks and Indemnity Agreement

COVID 19 Waiver

Electronic Signature *

By typing your name below you are providing an electronic signature of approval for the above Release of Liability, Waiver of Claims, Assumption of Risks and Indemnity Agreement, & COVID 19 Waiver. *Parent or Guardian sign for child if 17 years of age or under.*

Visit our DC16 VAC Calendar for upcoming events near you!

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms