Preferred Name *

First Name

Last Name

Address Type *

Work

Home

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Fax Number

(###)

###

####

Gender *

Male

Female

Birthdate *

The minimum age to participate in the Carter Work Program is 16. Please look back at our website for other opportunities to volunteer. If you are not currently 16 but will be by the start date of the trip you wish to apply to, please contact our office at alesia@habitat4inlandvalley.org.

MM

DD

YYYY

Expiration Date *

MM

DD

YYYY

Traveling with a companion or group

Yes

No

Companion Name

First Name

Last Name

Previous Affiliate Work?

Yes

No

Hobbies

Artist

Backpacking

Biking, Cycling

Camping

Canoeing, Kayaking

Cooking

Gardening

Hiking, Trekking

Music

Photography

Rafting

Reading

Running

Travel

Scuba Diving

Sewing, Quilting

Woodworking, Crafts

Theater

Skills

Art

Book Keeping

Construction

Electrical

First Aid / CPR

Masonry

Medical Professional

Ministry

Organizational

Photography

Plumbing

PR

Singing

Writing

Jimmy Carter Work Program Release and Waiver of Liability *

PLEASE READ CAREFULLY! THIS IS A LEGAL DOCUMENT! This Release and Waiver of Liability (the "Release") executed on this day of submission by above named applicant (the "Volunteer"), and in effect for one full calendar year from this date, in favor of HABITAT FOR HUMANITY INTERNATIONAL, INC. and Habitat for Humanity Inland Valley, a nonprofit corporation organized and existing under the laws of the State of Georgia, USA, its affiliated organizations in other nations, its directors, officers, employees, and agents (collectively, "Habitat";). I, the Volunteer, desire to work as a volunteer for Habitat and Partners and engage in the activities related to being a volunteer ("Activities"). I understand that my Activities may include but are not limited to the following: working in the Habitat for Humanity offices or Habitat for Humanity ReStore operations; traveling to and from work sites, towns, cities or countries; consuming food available or provided; living in housing provided for volunteers; constructing and rehabilitating residential buildings; painting and landscaping properties; and other construction-related activities. I, the Volunteer, hereby freely, voluntarily and without duress execute this Release under the following terms: Release and Waiver. I, the Volunteer, do hereby release and forever discharge and hold harmless Habitat and Partners and their successors and assigns from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my Activities with Habitat and Partners. I understand and acknowledge that this Release discharges Habitat and Partners from any liability or claim that I may have against Habitat and Partners with respect to any bodily injury, personal injury, illness, death or property damage that may result from my Activities with Habitat and Partners, whether caused by the negligence of Habitat and Partners or their officers, directors, employees, agents or otherwise. I also understand that Habitat and Partners do not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance in the event of injury, illness, death or property damage. Insurance. I, the Volunteer, understand that, except as otherwise agreed to by the Released Parties in writing, the Released Parties are under no obligation to provide, carry or maintain health, medical, travel, disability or other insurance coverage for any Volunteer. Each Volunteer is expected and encouraged to obtain his or her own health, medical, travel, disability or other insurance coverage. It is the policy of Habitat for Humanity that children under the age of 16 are not allowed on a Habitat for Humanity work site while construction is in progress. It is further the policy of Habitat for Humanity that, while children between the ages of 16 and 18 may be allowed to participate in construction work, ultra hazardous activity such as using power tools, excavation, demolition or working on rooftops is not permitted by anyone under the age of 18. Medical Treatment. . I, the Volunteer, do hereby release and forever discharge Habitat and Partners from any claim or action whatsoever which arises or may hereafter arise on account of any first aid, treatment or service rendered in connection with my Activities with Habitat and Partners. If the Volunteer is less than 18 years of age (a "minor"), the Volunteer and the parents having legal custody and/or the legal guardians of the Volunteer (the "Guardians") also hereby release and forever discharge Habitat and Partners from any claim w hatsoever which arises or may hereafter arise on account of the decision by any representative or agent of Habitat and Partners to exercise the power to consent to medical or dental treatment as such power may be granted and authorized in a Parental Authorization for Treatment of a Minor Child. Assumption of the Risk. I, the Volunteer, understand that my Activities may include work that may be hazardous to me, including, but not limited to, the following: construction; loading and unloading; travel to and from the work sites; and exposure to lead and mold, which may cause or worsen certain illnesses, especially if I do not wear protective equipment, am exposed for extended periods of time, or have a pre-existing immune system deficiency. I also understand there is some inherent risk in consuming local foods and living in local accommodations in the city(ies) or country(ies) visited. I further understand I may be traveling to and from locations where there is a risk of terrorism, war, insurrection, criminal activities, inclement weather or other circumstances that could threaten my health or safety. I also understand that it is the policy of Habitat and Partners to not pay ransom or make any other payments to secure the release of hostages. I hereby expressly and specifically assume the risk of injury or harm in the Activities and release Habitat and Partners from all liability for any loss, cost, expense, injury, illness, death or property damage resulting directly or indirectly from the Activities. Insurance. I, the Volunteer, understand that, except as otherwise agreed to by Habitat and Partners in writing, Habitat and Partners are under no obligation to provide, carry or maintain health, medical, travel, disability or other insurance coverage for any Volunteer. Each Volunteer is expected and encouraged to obtain his or her own health, medical, travel, disability or other insurance coverage. Photographic Release. . I, the Volunteer, do hereby grant and convey unto Habitat and Partners all right, title and interest in any and all photographic images and video or audio recordings made by Habitat and Partners during my Activities with Habitat and Partners, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings. Other. I, the Volunteer, expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia, USA, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia, USA. I further agree that in the event any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining clauses or provisions of this Release, which shall continue to be enforceable. Further, a waiver of a right under this Release does not prevent the exercise of any other right. By checking "I Agree", you are acknowledging that you have read, understand, and agree to the terms and conditions of this Release and Waiver of Liability. You further acknowledge that by clicking "Submit", you are creating an electronic signature and that you understand it will be binding, enforceable and the legal equivalent of a handwritten signature.

I Agree

I Disagree

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION *

I, the above named volunteer , authorize the following entities to disclose my health information to Habitat for Humanity International, Inc., its affiliated companies, and their officers, directors, volunteers, agents, employees and their authorized representatives (collectively "Habitat"): ACE American Insurance Company, its affiliated companies, and any authorized representatives ("Company"). My health information includes any and all information relating to my health which is in the possession of Company, including but not limited to medical and dental records, medical consultations, treatments, or surgeries; psychiatric or psychological care; use of drugs or alcohol; drug prescriptions; and communicable diseases, including HIV/AIDS. I understand the health information to be disclosed includes information protected under Federal and State law, including regarding mental health, substance abuse, developmental disabilities, infectious/communicable diseases, privileged communications and genetic information. I understand that the disclosure to Habitat is for the following purposes: eligibility confirmation; claim submission facilitation; claim inquiry and dispute resolution; fraud detection; and audit and quality control services. I understand that the signing of this Authorization is voluntary and is not required to receive benefits under any Company insurance policy. I understand that information disclosed under this Authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may request a copy of this Authorization. I agree that a photographic copy of this Authorization shall be as valid as the original. I understand that this Authorization is valid for the longer of 12 months or the duration of any claim for benefits under any Company insurance policy, but in no event longer than 24 months. I understand that I may revoke this Authorization at any time by providing written notification to the Company at ACE North American Claims c/o ACE A&H Claims, One Beaver Valley Rd, Wilmington, DE. 19803. Such revocation shall not have any effect on actions that the Company and/or Habitat took in reliance on the Authorization prior to each receiving notice of the revocation. By Checking "I Agree," I acknowledge that I have read, understand, and agree to the terms and conditions set forth above.

I Agree

I Disagree