Workforce Housing Support in Black Hills by Habitat

Name *

Over 18? *YesNo

Date of Birth *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone (Primary) *

What is your primary phone? *MobileWorkOther

Phone (Secondary)

What is your secondary phone? *MobileWorkOther

Email Address *

Group or Employer

Church/Faith Organization

Emergency Contact Information

Name *

Phone (Primary) *

What is your primary phone? *MobileWorkOther

Waiver of Liability & Release of a Minor

The Volunteer hereby freely, voluntarily, and without duress executes this Release under the following terms: *Initials Required

1. Release and Waiver. I expressly agree that this Release is intended to be as broad and inclusive as permitted by, governed by, and interpreted in accordance with the laws of the State of South Dakota. I understand that this Release forever discharges Habitat and its successors and assigns from any liability or claim that I may have against Habitat with respect to any bodily injury, personal injury, illness, death, or property damage that may result from my activities with Habitat, whether caused by the negligence of Habitat or its officers, directors, employees, or agents or otherwise. I understand that Habitat does not assume any responsibility for or obligation to provide financial assistance or other assistance. I understand activities may include, but are not limited to: construction; landscaping; power tool usage; loading and unloading of materials; transportation to and from work sites; and clean-up of residential home construction sites. *Initials Required

2. Assumption of the Risk and Medical Treatment. I understand that Habitat does not carry or maintain health, medical, or disability insurance coverage for any volunteer; and I hereby expressly and specifically assume the risk of any activities with Habitat and release Habitat from all liability for injury, illness, death or property damage resulting from the activities. In addition, I hereby release and forever discharge Habitat from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with my activities with Habitat. *Initials Required

3. Photographic Release. I hereby grant and convey unto Habitat all right, title and interest in any and all photographic images and video or audio recordings made by Habitat during my activities with Habitat, including, but not limited to: any royalties; proceeds; or other benefits derived from such photographs or recordings. *Initials Required

By signing below, the Volunteer and, if applicable, the parent/guardian, has read, understood, and executed this Release as of the date first above written.

Volunteer Name *

Date *

(IMPORTANT: If the Volunteer is less than 18 years of age, all parents or guardians must also sign this Release and Waiver of Liability)

Parent/Guardian Name *

Date *

Volunteer Information and Waiver of Liability

We're Here for You!

Emergency Contact Information

Waiver of Liability & Release of a Minor