Volunteer Info & Consent Form

We ask that all HDA adult volunteers, as well as those under 18 (with the help of a parent or guardian), complete a Volunteer Consent Form, which is due upon arrival.

If you have questions, call us at 606-436-0497 or email janie@hdahome.org.

Volunteer Info & Consent Form

"*" indicates required fields

Name of Volunteer*

First Last

Age (if under 18)

Address*

Street Address Address Line 2 City State ZIP Code

Name of Church/Group*

Work Dates*

When is your church/group scheduled to work with HDA?

Emergency Contact (of a person not on this trip)

Name of Contact*

First Last

Relationship*

Address (if different from the address you included above)

Street Address Address Line 2 City State ZIP Code

Day Phone*

Evening Phone*

Health Information

Allergies, Health Problems, or Concerns

Are there any Dietary, Medical or any other special needs we need to be aware of?

Are there any medicines you can't take? If so, please list it/them.

Name of Insurance Company

Insurance Company Phone Number

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Policy No.

Policyholder's ID #

Agreement

Volunteers participating with the Housing Development Alliance, Inc. (HDA) will be involved in new construction and repair of homes and other construction-related activities. They may also participate in free time activities. Planned evening activities may include visits to places of regional interest. Note: volunteers are not required to engage in any work or recreational activity in which they feel they are not able to participate safely. The foregoing statement of activities has been read and understood. HDA, its agents, employees, and all persons connected therewith are hereby discharged from any and all liability, claims, and cause of action arising out of participating with HDA. Further consent is given to be treated by competent medical personnel as a result of any accident or medical emergency while involved in the activities of HDA. The participant and guardian grant and convey to HDA all rights, title, and interest in any and all photographic images and video or audio recordings made by HDA during participation in activities.

Today's Date*

Signature of Participant

I certify that I am 18 years of age or older.

Signature of Parent or Legal Guardian (if participant is a minor)

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Name

This field is for validation purposes and should be left unchanged.

Volunteer Info & Consent Form