2020 Point in Time Count Volunteer Registration
Email address *
Name (first and last) *
Your answer
Address *
Your answer
Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Agency Affiliation (if any)
Your answer
Which part of the count are you available to participate? Please choose up to 3 options. NOTE: Checking only one box does not guarantee that will be your volunteer time. Volunteer assignments are based on the number of site locations available during each time slot. *
Required
Release
In consideration of the opportunity given to me to participate in volunteering with the Community Shelter Board (the "Activity"), I hereby, for myself, my heirs, executors, administrators and assigns, knowingly and voluntarily enter into this release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Community Shelter Board, located at 355 East Campus View Blvd, Suite 250, Columbus, Ohio 43235, its officers, trustees, employees, volunteers, tenants, affiliates, agents and the heirs, executors, successors and assigns of the foregoing from any liability, costs or expenses, for any accident, injury or death or any theft or loss of property that I may suffer arising out of or in connection with my participation in the Activity, including traveling to and from the Activity or any event related to the Activity, whether incurred as a result of negligence or otherwise.
I am voluntarily participating in the Activity, and I am aware of the risks associated with traveling to and from as well as participating in the Activity. In the event that I should require medical care or treatment as a result of participating in the Activity, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
I agree to indemnify and hold harmless Community Shelter Board against any and all costs or expenses including attorney's fees and any related costs of any kind whatsoever incurred in connection with litigation brought by me or by anyone on my behalf resulting from my participation in the Activity.
I acknowledge that Community Shelter Board and its officers, trustees, employees, volunteers, tenants, affiliates and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Community Shelter Board as part of or related to the Activity.
I grant Community Shelter Board and its officers, trustees, employees, volunteers, tenants, affiliates and agents the right to take photographs of me and my property in connection with the Activity. I authorize Community Shelter Board, its successors, assigns and transferees to use or publish the same in print and/or electronically and to register the copyright to the photograph. I agree that Community Shelter Board may use such photographs of me with or without my name and with any text or caption and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.
In the event that any damage to equipment or facilities occurs as a result of my willful actions, negligence or recklessness while participating in the Activity, I acknowledge and agree to be fully liable for any and all costs associated with such actions, negligence or recklessness.
I acknowledge and agree that (1) the individuals I am interacting with during the count have a right to privacy, and (2) by signing this release, I have an affirmative obligation and responsibility to maintain confidentiality of all information about individuals obtained or accessed by me in the course of this Activity. I agree not to divulge, publish or otherwise make known to unauthorized persons or to the public any information obtained in the course of the Activity that could identify individuals or their residential status unless I am specifically authorized to do so by Community Shelter Board acting in response to applicable law, court order or a public health or clinical need. I understand that violation of the terms of this paragraph will result in formal complaints and legal action when violations of applicable law occur.


I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing the release. I certify that I have read this release, and that I fully understand its content. I am aware that this is a full and complete release of liability and a contract, and I am signing it of my own free will. *
A copy of your responses will be emailed to the address you provided.
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