Lions of Michigan Foundation Project KidSight Volunteer Application, Understanding and Background Check Authorization Form
In consideration of participating in the KidSight Program, as a Vision Technician, Volunteer or Program Coordinator, I acknowledge and agree to the following:  I am aware of the existence of the risk relative to a person's physical appearance at a KidSight screening event and resulting from an individual's participation in a KidSight screening event that may cause injury or illness, such as but not limited to Influenza, MRSA, or COVID-19 and that may lead to paralysis or death, and I hereby declare that I am fully and personally responsible for my own safety and actions while and during my participation in the KidSight Program.

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Volunteer Position Requested *
Certified Vision Technician's must be trained and certified by a Lions District KidSight Program Coordinator before applying for a Certified Vision Technician position.  KidSight Program Coordinators are appointed annually by the Lions District Governor.  Contact your District Governor for information regarding your KidSight Program Coordinator(s) or contact the Lions of Michigan Foundation office at 517-887-6640 or info@lmsf.net.
Required
Lions Club  - Group Affiliation *
Lions District *
First Name *
Your legal first name as it appears on your Driver's License or Identification Card.
Middle Name *
Your legal middle name as it appears on your Driver's License or Identification Card.
Last Name *
Your legal last name as it appears on your Driver's License or Identification Card.
First Name or Nickname for your KidSight Identification Card *
The first name or nickname you would like to appear on your KidSight Identification Card.
Ethnicity
Clear selection
Date of Birth *
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DD
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YYYY
Gender Identification *
Home Mailing Address *
City - State - Zip Code *
Telephone Number (Daytime) *
Email Address
Check all applicable boxes.
Have you ever been convicted of felony crime? *
Required
Are there felony charges pending against you at this time? *
If you have previously been convicted of a felony crime, or if there are felony charges pending against you at this time, please explain.
Parent or Guardian's Name (Volunteers Under Age 18) - First Name and Last Name
With full knowledge of the risks involved for participation in the KidSight Program as a Vision Technician, Volunteer or Program Coordinator, I hereby release, waive, and discharge the Lions of Michigan Service Foundation, Inc., its board, officers, independent contractors, partners, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained, and I agree to indemnify, defend, and hold harmless the aforementioned from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising from or related to my participation in the KidSight Program.  Furthermore, I understand that I may not be allowed to begin volunteer work with the Lions of Michigan Foundation and its KidSight Program until my volunteer application and criminal background check has been processed and approved.  By checking the Electronic Signature Box below, I acknowledge that I am at least eighteen (18) years old and fully competent to give my consent for participation in the KidSight Program and for a criminal background check to be completed. *
Required
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