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Care 4 a Healthy Community - Volunteer Application

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[1],[2]

Contact Information:

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Please enter your first namePlease enter a valid name
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[2]
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Please select a T-Shirt size
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Volunteers can be 18 years or above. Please check this if you are 18 years or above
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Please enter the allergies if any

Person to contact in case of an emergency:

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[2]
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Please enter your relationship with the contact person
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Sunday, October 29th, 2017 at Indian Springs High School (650 N. Del Rosa Dr. San Bernardino, 92410)

Please select a shift

Volunteers Information

Greeter, usher, provide participant information, assist participants with registration, crowd control, restock supplies, material distribution, run errands, provide security, assist in directing parking, assist with event set-up and shut down.

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Please select any one volunteer type
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Please enter the School Name
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Please select at least one Language Option Please specify the Language
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Please select an Employer Please specify other Employer details
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Please enter the Healthcare License

Disclaimer

Each event has a maximum amount of volunteers needed, a confirmation will be sent to you with event details. You must receive confirmation from the event organizers to ensure you are listed.

Agreement and Signature:

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer for Care for A Healthy I.E., any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Publicity Authorization

By submitting this application, I give to Molina Healthcare, Inc., American Family Care, Inc. (Molina Medical Group), Buddhist Tzu Chi Medical Foundation, and each of the aforementioned entities' nominees, agents, and assigns, unrestricted and irrevocable permission to use, publish, and republish for purposes of advertising, trade, or any other lawful use, information about me and reproductions of my likeness (photographic or otherwise) and my voice, whether or not related to any affiliation with the Molina Healthcare, American Family Care (Molina Medical Group), and Buddhist Tzu Chi Medical Foundation, with or without my name.

Waiver and Release from Liability

BY CHECKING THE BOX BELOW, I AGREE TO INDEMNIFY AND HOLD HARMLESS MOLINA HEALTHCARE, INC., AMERICAN FAMILY CARE, INC. (MOLINA MEDICAL GROUP), BUDDHIST TZU CHI MEDICAL FOUNDATION AND EACH OF THE AFOREMENTIONED ENTITIES' SUBSIDIARIES, AFFILIATES, SUCCESSORS, ASSIGNS, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, SHAREHOLDERS AND INSURANCE CARRIERS (COLLECTIVELY, THE "RELEASED PARTIES") FROM AND AGAINST ANY AND ALL INJURIES, LOSS, LIABILITY, DAMAGE, COST, DEMAND, SUIT, ACTION, JUDGMENT OR EXPENSE WHATSOEVER (INCLUDING REASONABLE ATTORNEYS' FEES AND COURT COSTS) (COLLECTIVELY REFERRED TO AS "LOSSES"), ARISING OUT OF OR IN CONNECTION WITH MY PARTICIPATION IN CARE 4 A HEALTHY I.E. (THE "HEALTH FAIR"), WHETHER KNOWN OR UNKNOWN, INCLUDING, WITHOUT LIMITATION, ANY INJURY, DISABILITY, LOSS OF LIFE OR DAMAGE TO PROPERTY, ARISING OR RESULTING FROM, IN WHOLE OR IN PART, MY PARTICIPATION IN THE HEALTH FAIR UNLESS SUCH LOSS IS SOLELY CAUSED BY THE NEGLIGENCE OR INTENTIONAL MISCONDUCT OF A RELEASED PARTY.

Severability

I further expressly acknowledge and agree that the foregoing publicity authorization and the waiver and release from liability are intended to be as broad and inclusive as is permitted by the law of the State of California. If any portion thereof is held invalid, I agree that the balance shall, notwithstanding, continue in full legal force and effect.

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