Name
Today's Date
Date of Birth
Street Address
City
State
Zip
Home Phone
Cell Phone
Email
Driver's License #
Expiration Date
In case of emergency, please notify
Phone
Relationship
LIST THE TIMES YOU ARE AVAILABLE.
e.g., 9 AM – 1 PM, 3 PM – 5 PM. If you're not available on a certain day, please put "Not available."
Mon:
Tues:
Wed:
Thur:
Fri:
Available Start Date
Did Someone Refer you?YESNO
If Yes, who?
Offense
# of Hours Required
Probation Officer
Telephone Number
I understand that I may have access to personal information about clients and their household situations that is highly confidential. I may also have access to information regarding the operations of Harvesting Intl. Ministry Center, Inc., staff and other volunteers in the course of my work as a volunteer. I understand that this information is to be held in strictest confidence and is NOT to be discussed outside of volunteer meetings or with anyone except the staff of Harvesting Intl. Ministry Center, Inc. or other volunteers who have made similar pledges of confidentiality. Therefore, I pledge to keep the aforementioned information confidential as a condition of my volunteering and I understand that a breach of this pledge will be grounds for immediate termination from the volunteer program and possible legal action.
Volunteer Signature
As a voluntary participant in programs offered and administered by Harvesting Intl. Ministry Center, Inc., I, the undersigned, as one of the conditions of my participation, specifically release Harvesting Intl. Ministry Center, Inc., its officers, directors and employees from any claims by the undersigned or liabilities to the undersigned of any kind whatsoever, including, but not limited to, those claims which are actual or contingent, presently asserted or yet to be asserted, known or unknown, arising from or related to my participation in those activities or Harvesting Intl. Ministry Center, Inc., even if caused by the negligence of Harvesting Intl. Ministry Center, Inc., its officers, directors, or employees. In addition, I agree to indemnify, defend and hold harmless Harvesting Intl. Ministry Center, Inc., its officers, directors, and employees, from and against any claims by third parties or liabilities to third parties of any kind whatsoever caused by my negligent acts.
Volunteer Initials
I understand I will not receive any compensation, either financial or material (including food items), for time, work, or services that I may provide as a volunteer. My volunteer status does not prohibit me from applying for any services offered by Harvesting Intl. Ministry Center, Inc., and if eligible, receiving such services. If I receive assistance from Harvesting Intl. Ministry Center, Inc., I also understand that this will not cancel my responsibilities as a volunteer. I further understand that my volunteer status does not entitle me to receive any resources, whether grant provided, donated, or purchased that are intended for Harvesting Intl. Ministry Center, Inc. clients, unless I am eligible for such services.
Harvesting Intl. Ministry Center understands that situations arise and you may not be able to come in at the times you have listed. However, we do ask that, if at all possible, you contact your Harvesting International supervisor 24 hours in advance if you will not be able to keep your commitment.
Date Signed
Donate
Monthly Partner