Labouré Exchange Volunteer Form

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Thank you for your interest in volunteering at Labouré Exchange, VMY SEMO's thrift store. As a volunteer, your work is critical to the success of our ministerial efforts. Your work impacts individuals and families throughout our community. To participate please complete the following form. For help with questions or further information, contact Alina Korn, Director of Operations, at 573-883-7200 or via email at akorn@vmysemo.org.

Email *

Name *

Address *

Home Phone Number

Cell phone number *

Yes

Date of Birth

YYYY

Can we text you about volunteer opportunities? *

yes

Have you been convicted of a Felony? *

yes

If yes please explain. (type NA if the previous answer was no) *

Is this court-mandated? *

yes

If yes, please explain. (type NA if the previous answer was no) *

Name of Parol Officer/ Court Contact If Mandated

Parol Officer/ Court Contact Phone if Mandated

Name of Physician *

Physician Phone Number *

Allergies *

Will you be taking any medications while volunteering at Labouré Exchange *

Yes

Emergency Contact Name *

Emergency Contact Phone Number *

Relationship *

Can you perform the work assigned with or without any special accommodations? *

Yes

What accommodations are needed? *

Please Check Each Box to Signify Agreement *

I understand that in sining this form I hereby state that the information included in this form is correct and true.

I understand that I will be part of the Vincentian Marian Youth & Labouré Exchange volunteer group.

I in accordance with the guidelines of Vincentian Marian Youth & Labouré Exchange will follow, support, and enforce the guidelines as written and stated.

I recognize that there are risks inherent in participation in any activity and agree to hold harmless Vincentian Marian Youth, Labouré Exchange, its director, officers, employees, affiliates, staff and agents for any injury, damage to, or loss not caused by the negligence Vincentian Marian Youth, Labouré Exchange, its director, officers, employees, affiliates, staff and agents.

In case of medical emergency I hereby give my permission for Vincentian Marian Youth, Labouré Exchange, its director, officers, employees, affiliates, staff and agents to contact appropriate medical professionals in order that I may be evaluated, diagnosed, and treated in accordance with standard medical practice by a licensed medical professional.

For good and valuable consideration, the sufficiency of which is hereby acknowledged, I, the undersigned grant Vincentian Marian Youth the right to publish, reproduce and display photographic images, video images and/or audio recordings of my VMY Student Member for use in all media, electronic or otherwise, in connection with publications, advertisements and/or web pages of VMY, provided that VMY is not authorized to sell or otherwise distribute such photographic images, video images or audio recordings to any other person or entity without my consent. I understand that VMY may associate the photographic image, video image or audio recording with the first name of the Individual and the name of the organization of which the Individual is a part of. I further acknowledge and agree that I nor individual, if individual is a minor, shall have no ownership interest in any informational or advertising material which utilizes, incorporates or consists of the photographic images, video images and/or audio recordings or in any copyright embodied therein.

I understand that the use of any mood altering chemical, including but not limited to alcohol and illegal drugs, tobacco, foul language, threats of any types, abuse, theft, inappropriate physical conduct or violation of the volunteer rules and regulations may result in the removal from the premises, contacting of authorities and the removal from future volunteer activities.

Required

Signature (Type Full Legal Name) *

Date *

YYYY

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