Volunteer Form

*First Name

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*Last Name

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*Address

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*City

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*State

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[1]Phone Number

[2]Cell Number:

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*Email Address

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*T-Shirt Size

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* I certify that I am at least 18 years old. Volunteers under 18 years old are not permitted.

Volunteers can be 18 years or above. Please check this if you are 18 years or above

* Do you have medical insurance? Yes No Please select Yes/No

*Please list any allergies:

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*Name

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[1]PhoneNumber

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*Relationship

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Sunday, October 29th, 2017 at Indian Springs High School (650 N. Del Rosa Dr. San Bernardino, 92410)

Shift #1: 6:00 a.m. - 3:00 p.m.

Please select a shift

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.

* Student Medical Assist LVN RN Dental Assistant Dental Hygienist General Volunteer

Please select any one volunteer type

*Name of School:

Please enter the School Name

* Do you speak another language? Yes No Please select Yes/No

*Please select language(s):

Please select at least one Language Option Please specify the Language

* Are you comfortable interpreting medical terminology: Yes No Please select Yes/No

* Are you a Molina employee?: Yes No Please select Yes/No

*Employer? :

Molina Healthcare Of California Molina Medical Group/Molina Medical Management Molina Healthcare Inc. Other

Please select an Employer Please specify other Employer details

* Are you a Healthcare Professional?: Yes No Please select Yes/No

Healthcare Degree:

*Healthcare License #:

Please enter the Healthcare License

Licensing State:

California Does not apply Other

License Comments:

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.

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.

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.

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.

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.

*Name

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*Date:

Care 4 a Healthy Community - Volunteer Application

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Volunteers Information

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