Gleaning Volunteer Assumption of Risk and Release of All Claims
Thank you for volunteering to participate in a Merrymeeting Food Council gleaning event. We appreciate that you have chosen to spend time with us. Before you begin, we need you to know that volunteering to perform gleaning activities on any farm can expose you to personal injury or damage to your property. This waiver outlines our respective rights and responsibilities relating to that risk. Please read this waiver carefully and let us know if you have any questions.
Email address *
Full Name
Your answer
Date of Birth (00/00/0000) *
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Phone Number *
Your answer
How do you plan to help? Check all that apply.
Times Available (check all that apply) *
Morning
Afternoon
Not Available
Weekdays
Weekends
Are you available to volunteer with us long-term, or will you be volunteering one time? *
Where would you like to volunteer? (check all that apply) *
Required
Can you provide your own transportation? *
Are you willing to deliver produce after gleaning? *
If you are part of a group that wants to get involved please provide the name and contact information for your organization as well as an approximate number of volunteers.
Your answer
Volunteer Status (type full name if you agree) - I would like to volunteer in Merrymeeting Food Council gleaning activities at various farms and farmers' markets sites. I understand that as a volunteer I will not be paid for my efforts and I will not be covered under workers compensation insurance. *
Your answer
Risks of Volunteering (type full name if you agree) - I understand that the gleaning activities on a farm involve serious risks. I may be exposed to: insects; wildlife; farm animals; inclement weather; extreme temperatures; heavy machinery; tools; the actions and negligence of employees, volunteers and other people present on the farm; and dangerous conditions on the land such as holes in the ground or barbed wire. I understand that these examples are not all-inclusive and there may be additional risks, all of which may involve serious personal injury, death or damage to my property. *
Your answer
Release of Claims and Assumption of Risk (type full name if you agree) - In exchange for the opportunity to participate in Merrymeeting Food Council gleaning activities on the Farm, I (and my family, heirs, and personal representatives) willingly and knowingly release Merrymeeting Food Council, and the Farm, and their officers, owners, employees and agents from any and all liability for any personal injury or damage relating to my participation. I (and my family, heirs, and personal representatives) agree to assume all of the risks and responsibilities of my participation. I understand that I am solely responsible for any hospital or other costs arising out of any personal injury or property damage relating to my participation in Merrymeeting Food Council gleaning activities. *
Your answer
Medical Care Authorized (type full name if you agree) - I am physically fit to participate in Merrymeeting Food Council gleaning activities on a Farm. I understand that there are no medical services available on site and I give permission to the Merrymeeting Food Council to authorize emergency medical treatment for me. I release the Merrymeeting Food Council and the Farm and their officers, owners, employees and agents, from liability for any injury or damage that might extend from such emergency medical treatment. *
Your answer
I further agree that this waiver should be interpreted as broadly and inclusively as the law of the State of Maine permits. (type full name if you agree) *
Your answer
Emergency Contact (Name, Relationship to Volunteer, Primary Phone, Alternate Phone) *
Your answer
Please list any medical concerns, allergies, and/or any other information which any medical first responder should be made aware: *
Your answer
Media Release (type full name if you agree) - I do consent to and allow any use and reproduction by Merrymeeting Food Council of any and all photographs or videotapes taken of me during my participation in volunteer activities through Merrymeeting Food Council events, programs, and activities. I understand that Merrymeeting Food Council will own the photographs and videotape and the right to edit them or prepare derivative works for the purposes of promotion, advertising, and public relations. I hereby consent to Merrymeeting Food Council's use of my name, likeness or voice, and I agree that such use will not result in any liability for payment to any person or organization, including myself.
Your answer
Today's Date *
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