VITA Volunteer Application

Volunteer information

Legal first name

Legal last name

Middle initial

Prefix

Preferred first name

Preferred last name

Address

City

State

Zip code

Date of birth

Contact information

Primary phone number

This is my

Alternate phone number

This is my

Email address

Alternate email address

Emergency contact information

Emergency contact name

Emergency contact phone number

Emergency contact relationship

Medical conditions/allergies

Terms

I agree to the media release below.

This will confirm that the undersigned, having the sole right to do so, for good and valuable consideration (the receipt of which is hereby acknowledged), grants to United Way of Racine County, to include United Way Worldwide and its affiliated organizations, members, successors, assigns and licensees, a non-exclusive and irrevocable right to photograph, record, reproduce, publish, copyright, or otherwise use my name, photographic portraits or pictures, film, videos, internet postings, or sound recordings or any part thereof that may have been taken of me during United Way events and/or activities in written or electronic format, video or film (Content) for promotional, advertising, or other charitable purposes in any media including the world wide web related to the United Way community impact activities. This also includes any tweets or messages through social media.

I acknowledge and agree that nothing contained herein requires United Way to use any Content as described herein.

I represent and warrant that the consent of no other third party is required to enable United Way to use the Content as described herein, and that such use will not violate or infringe upon the rights of any third parties.

I acknowledge and agree that United Way has the right to assign this agreement and/or the rights herein (in whole or in part) to any party.

I acknowledge that its sole remedy for any breach shall be an action for damages, and irrevocably waive any right to obtain equitable or injunctive relief.

I waive any right of inspection, preapproval, or claims for compensation.

I am of full age and have the right to contract in your own name and have read the above consent and permission and are fully aware of its contents. In the event I am a minor, the signature of a parent or legal guardian is required. I will contact United Way of Racine County to make further arrangements.

This Consent and Release contains the full and complete understanding between the parties and supersedes all prior agreements and understandings pertaining hereto and cannot be modified except by a writing signed by each party.

I agree to the background check terms listed below.

I understand that my eligibility to be a volunteer is dependent on my background check results. I understand that before I am able to volunteer, I am responsible for submitting my personal information to Sterling Volunteers in order to provide a background check to United Way of Racine County. I certify that the answers given by me to Sterling Volunteers will be complete, true, and correct without misrepresentations or omissions of any kind.

I understand that United Way of Racine County shall not be held liable in any respect if my volunteering is terminated because of false or incomplete statements, answers or omissions made by me on the disclosure form of any other document. In consideration of United Way of Racine County’s review of the document, I hereby release United Way of Racine County, its Board, its agents, as well as all providers of information from any liability and for any damage which may result from the furnishing and receiving of information. A copy of this authorization and release is as valid as the original and should be recognized as such.

If accepted as a volunteer, I understand that I will be expected to keep in absolute confidence any and all confidential information that comes to my attention as the direct result of my volunteer duties.

VITA Volunteer Application

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