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Northwest Ohio - Volunteer Application and Waiver

Please fill out the following form to receive information about volunteering with Susan G. Komen Northwest Ohio.

 

Volunteer Application

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Question - Required - Date




2. Your information:

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Name:

 

 

   

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City/State/ZIP:

 

    

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Date of Birth:

 

 

 


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NOTE: Before answering this question regarding criminal convictions please refer to the instructions below.

A “yes” is not an automatic bar to volunteer service with the Susan G. KomenŽ Northwest Ohio ; the circumstances relating to the offense will be considered in relation to the volunteer position for which you are applying.  

INSTRUCTIONS FOR ANSWERING CRIMINAL CONVICTION INQUIRY


Ohio Applicants:  Do not identify convictions that are more than ten (10) years old.

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Not Required - Please select a volunteer opportunity that you would like further information about.
Please make at least 1 selection from the choices below.

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Question - Required - Please indicate if you have more than one year of experience in the following areas: (You may select multiple areas)

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Question - Not Required - How often would you like to volunteer?



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Question - Not Required - I'm interested in a:


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Emergency Contact:

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Information to Volunteer Applicants

(Read Carefully Before Signing)

You may be asked to sign an authorization for the Susan G. KomenŽ Northwest Ohio to fully investigate your suitability for volunteering (depending on the position and responsibilities) by obtaining information from your previous employers and/or other knowledgeable persons as to their firsthand experiences with you, and also, when deemed necessary, by obtaining reports from credit bureaus, credit agencies, or other consumer reporting agencies.  Under some circumstances, certain of such reports may be “consumer reports” or "investigative consumer reports" as to which, under the Fair Credit Reporting Act, you are entitled, upon your request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Susan G. KomenŽ Northwest Ohio .

 

Volunteer Applicant Statement

(Read Carefully Before Signing)

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation.  I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from the Susan G. KomenŽ Northwest Ohio .
If selected as a volunteer, I agree to comply with the rules and regulations of Komen Northwest Ohio .  
I also understand that smoking is prohibited in all indoor areas of the Susan G. KomenŽ Northwest Ohio .

 

Komen Volunteer Release

I wish to volunteer for Susan G. Komen Northwest Ohio (“Affiliate”). I understand that my consent to these provisions is given in consideration for being permitted to volunteer. I UNDERSTAND THAT THE NATURE OF MY VOLUNTEER ACTIVITIES MAY INVOLVE PHYSICAL ACTIVITY, CONTACT WITH UNIDENTIFIED OR UNFAMILIAR PERSONS, OR OTHER POTENTIAL RISK OF BODILY INJURY OR DAMAGE TO PROPERTY, AND I HEREBY VOLUNTARILY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR, AND THE RISK OF, ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY VOLUNTEER WORK. TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN, MY HEIRS, ADMINISTRATORS AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST THE AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. (“KOMEN HQ”), AND ALL OTHER AFFILIATES OF KOMEN HQ AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS, AGENTS, EMPLOYEES, VENDORS, CONTRACTORS AND PARTNERS (COLLECTIVELY, “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN CONNECTION WITH MY VOLUNTEER WORK. THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I OR MY RELEASORS MAY HAVE ARISING OUT OF MY VOLUNTEER WORK WITH THE AFFILIATE, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE CAUSED BY CONTACT WITH AND/OR THE ACTIONS OF OTHER PERSONS, CONTACT WITH FIXED OR NON-FIXED OBJECTS, NEGLIGENCE OF THE RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, OR OTHERWISE. I understand that as a volunteer, I may become privy to confidential information about a Releasee. I agree to maintain the confidentiality of any information marked confidential, as well as any information about each Releasee’s business operations, employee information, financial operations, marketing strategy, donor information, events, current or proposed business transactions and sponsorships, and any proprietary information such as computer software and programming that is not otherwise publicly disclosed. I will not use any confidential information in any manner that would be detrimental to a Releasee. At all times during my volunteer work, I will conduct myself in such a manner as not to reflect unfavorably on or in any way diminish the reputation of the Affiliate, Komen HQ and its affiliates. I give my consent and permission to the Affiliate, Komen HQ and their respective affiliates, successors, licensees, and assign the irrevocable right to use, for any purpose whatsoever and without compensation, any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of my volunteering. This Release shall be construed under the laws of the state in which the Affiliate is located. In the event any provision of this Release is deemed unenforceable by law, (i) the Affiliate shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this Release shall remain in full force and effect. 

I understand that I have given up substantial rights by accepting this Release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my acceptance to be a complete and unconditional release of liability to the greatest extent allowed by law. This Release extends to claims and facts unknown and unsuspected to exist at the time of executing this Release. All rights under Section 1542 of the California Civil Code are hereby expressly waived with respect to any of the claims, injuries, or damages described in this Release. Section 1542 of the California Civil Code reads as follows: A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

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