North Country Food Alliance Volunteer Electronic Waiver for On-Farm Gleaning

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The undersigned Volunteer has agreed to work as a volunteer for the North Country Food Alliance at their farm Partner site(s). As a Volunteer I understand that some of the activities performed by volunteers of the North Country Food Alliance involve a risk of injury, including the inherent risks associated with any harvesting and on-farm activities.

As a Volunteer I hereby expressly release, relinquish, and forever discharge the North Country Food Alliance, their farm Partner(s), and their respective successors and representatives (collectively, the “Released Parties”), of and from any and all claims, which the undersigned may have against the Released Parties arising out of volunteer service for North Country Food Alliance and any and all related activities at the farm Partner site(s).

Additionally, as a Volunteer I hereby authorize the North Country Food Alliance and their farm Partners to take photographs of myself, the Volunteer, and to use or publish such photos (either still photos or film/video) as they see fit and I waive any rights and any claims I might have regarding the taking or publishing of any such photos.

Please make sure ALL information is filled out for every volunteer with the appropriate signature(s).

I consent to using an electronic signature to complete this waiver (if replying no, please do not fill out this form and instead you will be asked to fill out a paper copy upon arrival to our partner site). *

Yes

Required

PLEASE ANSWER THE FOLLOWING REQUIRED HEALTH SCREENING QUESTIONS. YOU WILL BE ASKED THE SAME QUESTIONS UPON ARRIVAL TO YOUR SHIFT.

I am at least 16 years of age.

I am comfortable lifting 25 lbs.

I have not traveled out of the state within the past 14 days.

My temperature is lower than 100.4 degrees.

I am not sick or exhibiting symptoms including fever, sore throat, or shortness of breath in the last 14 days.

I have not been around anyone with previous symptoms or a positive test for COVID-19 or influenza A and B.

I do not have a serious underlying medical condition.

I plan to glean with North Country Food Alliance during the 2021 season at the following farm Partner sites. By checking the box(es), I am indicating my plan to participate at the Partner site(s) and I am including the indicated farm Partner site(s) in this waiver of liability. *

Dream of Wild Health Farm in Hugo, MN

Philadelphia Community Farm in Osceola, WI

Other:

Required

Name (First, MI, Last) *

E-mail Address *

Telephone Number (xxx-xxx-xxxx) *

Home Address (Street Address, City, State, ZIP) *

Where did you hear about this gleaning opportunity?

Signature (your full legal name, typed, will serve as your e-signature) *

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