Volunteer ApplicationName(Required) First Last Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day Phone(Required)Evening Phone(Required)Email(Required) EmergencyEmergency Contact Name(Required) First Last Emergency Contact NameEmergency Contact Phone(Required)Relationship(Required)Education BackgroundPlease check the highest level completed. Elementary/Jr. High Diploma High School Diploma Associate’s/Technical Degree Undergraduate degree Master’s degree or higherName of SchoolYear of GraduationMajorEmployment - If Currently EmployedEmployerPositionVolunteeringPlease mark the program(s) you would like to volunteer with:(Required) Beautification Projects Client Activities - Adult Day Services Client Activities - Residential Special Events Youth Camp VolunteersPlease mark the days that work best for you. Mark all that apply:(Required) Weekdays Weeknights Weekends One Time Regularly Seasonally OtherWhat hobbies and skills do you have that may be useful in our programs? (ex. Painting, embroidery, music, baking)(Required)Describe any specialized training (ex. RedCross, CPR, CNA, HIPPA)(Required)How many hours would you like to volunteer?(Required)Please list any volunteer positions, responsibilities, and supervisors:(Required)Why are you volunteering at this time?(Required)What do you hope to gain from a volunteer experience?(Required)What do you hope to gain from a volunteer experience?(Required)Are you volunteering to fulfill a service requirement or to receive credit?(Required)Are you volunteering to fulfill a service requirement or to receive credit?YesNoHow did you learn about UCP Heartland's volunteer opportunities?(Required)Photo and Publicity Release(Required)Photo and Publicity ReleaseUCP Heartland MAY use photos, images, video recordings and/or other visual or audio representations and the like of me in promotional media.UCP Heartland MAY NOT use photos, images, video recordings and/or other visual or audio representations and the like of me in promotional media.Photos, videos and other visual and audio media play a key role in helping us share our mission with donors, volunteers, program participants, and the general public through promotional media. Promotional media includes website stories, social media posts, newsletters, videos, recruitment efforts, and other agency-related uses. We often take photos at volunteer events, but we will only share images and representations of you publicly if you grant permission. Please indicate your preference above.Consent(Required)Waiver & Release I understand that as a UCP Heartland volunteer, my volunteer activities may involve physical activity and other potential risks of injury. I hereby assume the risk for any accident or injury, to person or property, which I may sustain in conjunction with my participation as a volunteer. In addition, in return for being allowed to participate UCP Heartland’s volunteer activities and all related activities, I hereby release, hold harmless, and agree not to sue UCP Heartland or any of its successors, directors, officers, employees or affiliates (the Released Parties) for any claims arising from or related to my participation as a UCP Heartland volunteer, including any claims for property damage or injury, that may be made by me, my estate, or my assigns. I understand and agree that the Released Parties are not responsible for any injury or property damage related to my participation as a volunteer even if caused by their ordinary negligence or otherwise. I further understand that this agreement is intended to be as broad as permitted by the laws of Missouri and I agree that if any portion of this agreement is determined to be invalid, all valid, remaining portions will continue in full force and legal effect. UCP Heartland has my permission to share the information on this application with any prospective employer or, in case of emergency, to notify my emergency contact. I understand all information submitted within this application will be held in confidence according to the personnel policies of UCP Heartland. I further understand that an interview with UCP does not guarantee placement within their volunteer programs. About Volunteer Status I further understand and acknowledge that as a volunteer I will not be considered an employee of UCP Heartland and I will not be receiving compensation or benefits for my volunteer services. I am also willing to participate in all required training and complete all required forms as designated. Photo and Publicity Release I hereby release and hold harmless UCP Heartland and any of its successors, directors, officers, employees or affiliates from any and all liability for any claims by me or any third party in connection with my participation or in connection with any copying, modification, adaption, reproduction, display, or other dissemination of the above mentioned photos, images, video recordings and/or other visual or audio representations and the like , including, but not limited to, any infliction of emotional distress, defamation, or right to privacy claims. I acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the above mentioned photos, images, video recordings, etc. I further acknowledge and agree that publication of said photos, images, video recordings, etc. confers no rights to me of ownership or royalties whatsoever. Permission for Emergency Medical Treatment I understand that every attempt is made to ensure the safety of persons volunteering in United Cerebral Palsy Heartland (UCP) programs. When illness or accident occurs at a UCP Heartland program or activity site or during Agency transportation, a designated responsible adult will be contacted as soon as possible. There are times when the designated individual cannot be reached quickly enough to meet the immediate need. In the event of accident or illness requiring Emergency Medical Treatment by a physician or hospital, I hereby authorize UCP Heartland to secure necessary treatment for me. I further agree to assume financial responsibility for any such Emergency Medical Treatment and related costs. I understandSignatureName(Required) First Last Date(Required) MM slash DD slash YYYY If 16 years of age or younger parental permission is requiredParent/Guardian Name First Last Parent/Guardian NameEmergency Contact Name First Last Parent/Guardian NameEmergency Contact PhoneI give my permission for my son/daughter to volunteer with UCPHeartland. I agree.Parent/Guardian SignatureDate MM slash DD slash YYYY
