WSASC Volunteer Application
  WSASC |  Mailing Address: PO Box 11, North Bend, WA 98045  |   www.wsasc.org

Please fill out this form so we can get you on your way to finding the perfect volunteer opportunity. Thank you for applying to volunteer with the Washington State Association of Senior Centers (WSASC); your time and skills are appreciated!
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Name *
First and last name
Email *
Address (include City, State, & Zip Code) *
First and last name
Phone number (best daytime contact) *
Phone number (alternate number)
What organization or agency are you representing?
Skills and Experience: what general skills, experience, or education would you like to share in your volunteer work? *
WAIVER OF LIABILITY
In consideration of the opportunity WSASC has provided to engage in volunteer activities, I hereby agree to indemnify and hold harmless, release and waive all claims that I and/or my heirs, assignees, other successors, or any third party may have against WSASC, its officials, employees, its hired contracted instructors, agents, and other associated parties for and from any and all loss, liability, cost or damages, including personal injury or death, arising out of or in any way connected with the volunteer activities. Further, I assume liability for any non-participants who accompany me to the volunteer activity.
I grant the WSASC the right and permission to use or copyright, and re-use, publish or re-publish, photographs, video, electronic images, or other reproduction taken of my image during volunteer activity in any record of this event or its related activities or for any WSASC publicity purpose.
Emergency Contact Information
Name *
First and last name
Phone number *
Are you able to meet duties outlined in the position description, either with or without any reasonable ADA accommodations?
CONSENT FOR MEDICAL TREATMENT
I, the undersigned, hereby authorize and consent to qualified medical personnel, including a physician or other staff, to administer any first aid and/or emergency medical treatment, care or medication in the event of injury and to arrange for any consultation by a specialist, including a surgeon, as is deemed prudent for proper care or treatment of any injury or medical condition. I have attached information regarding relevant health conditions (allergies, medications, etc.)
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