Volume II: Appendix 3: Volunteer Forms

Appendix: Volunteer Forms

VOLUNTEER REGISTRATION FORM

This portion of the form to be filled out by the Volunteer:

Social Security No: _____________________ Last Name: ________________________

First Name:____________________________Middle Name:_____________________

Preferred First Name:___________________Date of Birth: ______________________

Gender: ο Female ο Male

Permanent Address: _______________________________________________

City: __________________ State: ________Zip Code: __________

Telephone #: _________________________________

Do you have health insurance? Yes ___ No ___ if yes, please provide the following optional

information: _________________________

Medical Insurance Carrier: (Optional)________________________________________________

EMERGENCY CONTACT INFORMATION:

Contact

Last Name: _____________________ First: ____________________Middle:_______________

Relationship_______________________

Address:

Street: ______________________________City: _________________State:______

Zip: ___________

Phone:( ____ ) -____________Ext:_________________

I have carefully read the Canisius University Volunteer Policy and information above and understand their contents. The above information provided by me is accurate.

________________________________________________________

Volunteer’s Signature Date

This portion of the form is to be filled out by the department supervisor:

Department Head	Title	Email Address

Unit	Telephone Number	Begin and End Dates

Description of Volunteer Duties:

______________________________________________________________________________

______________________________________ _________________

Department Head Signature Date

Please submit this form to Human Resources.

VOLUNTEER RELEASE AND WAIVER OF LIABILITY

Please read this document carefully before signing

I,__________________________________________________, desire to voluntarily participate without compensation in the department of________________________________, at Canisius University. Therefore, I hereby covenant with Canisius University that I shall not sue or bring any legal action or proceeding against Canisius University or its board of trustees, employees, agents, officers, faculty, students, or representatives on account of any injury or damage, including death, that I may sustain by virtue or arising out of my work as a volunteer and/or use of the equipment of Canisius University.

I acknowledge that my work as a volunteer and/or use of the equipment of Canisius University shall be at my sole risk and that Canisius University, its board of trustees, employees, agents, officers, faculty, students, or representatives shall not have any responsibility whatsoever with respect thereto.

I acknowledge that I have read this document carefully and that I fully understand and accept all provisions of the waiver.

I certify I am at least eighteen years of age and voluntarily sign this waiver.

Signature___________________________________ Date______________________________

Witness____________________________________ Date______________________________

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