Catholic Social Services of the Miami Valley

Volunteer Contact Information:

Todays Date:

____________________

Name:

________________________________________________

Address:

________________________________________________

Home Phone:

_________ )______________________
Emergency Contact:

Name:

________________________________________________

Address:

________________________________________________

Home Phone:

_________ )______________________

Alternate Phone:

_________ )______________________

Relationship:

_________________________________________

I understand that I am a volunteer for Catholic Social Services of the Miami

Valley. I understand that, as a volunteer, I may be involved in physical activities
that have a potential risk of injury. I assume that risk. I agree that I will only
perform volunteer activities that I am comfortable doing. I also agree that I will
not hold CSSMV and their former and current officers, directors, shareholders
and employees responsible or liable for any damage or injury to me or my
property as a result of my participation and I agree to be responsible for my
behavior.
I also grant full permission for organizers to use photographs or video footage of
me in legitimate accounts and promotions of this event.
Signature:

_______________________________ Date: ____/____/____

Agency Use:
Program for which volunteer assisted:
Type of volunteer:

One-day

________________________________

Short-term (______ days; ______ hours)