Name
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First Name
Last Name
Email
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Subject
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Volunteer Position Interest (events, office assistance, website/social media, internship, programming with children with ASD):
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Country
(###)
###
####
Drivers License State/#:
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Occupation
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Employer Name
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Phone Number
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If you are volunteering as part of a company or group, specify group:
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Do you frequently/habitually use illegal drugs?
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No
Yes
Have you ever been convicted of a criminal offense?
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No
Yes
Have you ever been charged with neglect, abuse, or assault?
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No
Yes
Has your driver’s license ever been suspended or revoked in any state?
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No
Yes
Have you ever been disciplined by an employer for sexual harassment or misconduct?
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No
Yes
Has your employer completed a criminal background check on you?
No
Yes
If “yes” to 1, 2, 3, 4, 5, or “No” to 6 please explain
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I understand that: * The information I have provided will be verified through others including a NCIS/SLED criminal background check, and I give permission to LAF to make inquiry of others concerning my suitability to act as a LAF volunteer; * I release LAF, all persons, organizations, or government agencies for any damages of, or resulting from, furnishing such information. * In the course of volunteering for LAF, I may be dealing with confidential information and I agree to keep said information in the strictest confidence; * The relationship between LAF and volunteers is an ‘at will’ arrangement, and it may be terminated at any time without cause by either the volunteer or LAF; * I grant LAF permission to use my likeness, voice, and works in television, radio, and film or in any form to promote activities of LAF. * Once accepted as a volunteer a criminal background check may be completed every three years as long as I am an active volunteer. * I have read and acknowledge that I understand and will abide by the Volunteer Code of Conduct. Page 2 of 3 LOWCOUNTRY AUTISM FOUNDATION RELEASE AND WAIVER OF LIABILITY * In consideration of participating in LAF, I represent that I understand the nature of the activity and that I (and/or my minor child am (are/is) qualified, in good health, and in proper physical condition to participate. I fully understand the event involves risks of serious bodily injury which may be cause by my own actions or inactions, by the actions of others participating in the event, or by conditions in which the event takes place. I fully accept and assume all such risks and all responsibility for losses, costs, and/or damages I (and/or my minor child) may incur as a result of my (and /or my minor child’s) participation. I acknowledge that at any time that if I (we) feel that the event conditions are unsafe, I (and/or my minor child) will discontinue participation immediately. * If during my participating in LAF activities I should need emergency medical treatment and I (and my minor child) am (are/is) not able to give my consent for or make my own arrangements for that treatment because of my injuries, I authorized to take whatever measures are necessary to protect my health and well-being, including, if necessary, hospitalization. * I (and/or my minor child) release, indemnify, covenant not to sue, and hold harmless LAF, its administrators, directors, agents, officers, volunteers, , and other participants, and sponsors, advertisers, and if applicable, any owners and lessors of premises on which the activity takes place for all liability, any losses, claims (other than that of the medical accident benefit), demands, costs, or damages that I (and/or my minor child) may incur as a result of participation in LAF events or activities and further agree that if, despite this “Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement,” I, or anyone on my behalf, makes acclaim against any of the Releases, I will indemnify, save, and hold harmless each of the Releases from any litigation expenses, attorney fees, loss, liability, damage or cost which may incur as a result of such claim. I affirm I have read the above and the information I have given is true and complete. Furthermore, I agree to notify if any information changes.
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Please include your initials that you read and understand the above.
By Checking This Box, you are electronically submitting your Signature
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