Name *

Name

First Name

Last Name

Date of Birth *

Date of Birth

MM

DD

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Liability Statement *

Liability Statement

I wish to volunteer my services to various community service organizations and projects through you, Community Servants, Inc. a not-for-profit Tennessee corporation. In consideration of your locating, arranging, coordinating and/ or making available volunteer opportunities, I hereby agree and release you as follows: 1. I acknowledge and agree that the nature of the volunteer services which are typically performed by Community Servants, Inc. and which may be performed by me as a volunteer, may involve (a) physical activity (including without limitation work with heavy tools and materials), (b) contact with unidentified and unfamiliar persons, (c) travel to and from various unspecified locations, and (d) other potential risk of injury. Notwithstanding the preceding sentence, I willingly and freely agree to volunteer and hereby assume any and all risk, with respect to any liability of Community Servants, Inc. for such risk, including without limitation risk of any accident or injury to person or property which I may sustain in connection with my participation as an Community Servants, Inc. volunteer or in any Community Servant, Inc. related project or activity. 2. The undersigned hereby releases you and your directors, officers, partners, agents, employees, successors, assigns, licensees, sponsors, donors, representatives, guests and affiliates from and covenants not to sue you for, any and all claims and causes of action, whether known or unknown, arising out of, based upon or relating to my participation as an Community Servants, Inc. volunteer or in any related activity or project. I hereby confirm, represent and warrant that I have never been convicted of a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection herewith. 3. I further irrevocably grant to Community Servants, Inc., its assigns and successors, my consent and full right to: use my name, photograph, likeness, image, voice and biography in any and all media, publications, advertising, and publicity, in connection with my participation hereunder. 4. This release shall inure to your benefit, as well as to the benefit of your successors, licensee, agents, employees, affiliates and assigns. This release shall be governed by the laws of the State of Tennessee. By typing my name, I agree to the above liability statement.

First Name

Last Name

Background Check *

Background Check

My signature below gives Community Servants, Inc. permission to perform a background check on me including: • Criminal records • Driving records • Employment verification/ volunteer history • Credit reports • Education/diploma verification • Personal references and other persons or sources as appropriate for the volunteer job in which I have expressed an interest. I understand that I do not have to agree to this background check, but refusal to do so may exclude me from consideration for some types of volunteer positions and that all such information collected during the check will be kept confidential. I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability for the described volunteer work and other such information, as they deem appropriate.

First Name

Last Name