-Volunteer: Release Form - Catholic HEART Workcamp

This form must be filled out by all volunteers (Youth, Adults, Clergy, Etc.)

Name *

First

Last

Nickname

Example: Robert is called Bob

Parish / Group *

Example: St. James, Orlando FL

Gender *

Male
Female

Camp *

Location your are volunteering

What is your current age? *

At the start of the camp, what age will you be? *

At the start of the camp, what age category will you fall into? *

CATHOLIC HEART WORKCAMP

MEDICAL INFORMATION & RELEASE OF ALL CLAIMS

Participant Date of Birth *

Emergency Contact *

First

Last

Emergency Contact, Relationship to Participant *

Emergency Contact, Phone Number *

Health Status: Please list any health problems you may have

Example: asthma, allergies, back trouble, diabetes, seizures, mental disorders or illnesses

Please list all medications taken routinely (over the counter and prescription)

Please include the name, dosage and reason for taking it.

Physician Name *

Physician Phone Number *

Date of your last Tetanus Booster

Preferred but not required.

Health Insurance

All participants must have health insurance in order to volunteer at CHWC.

Health Insurance: Provider *

Health Insurance: Policy Number *

Health Insurance: Group Number *

CATHOLIC HEART WORKCAMP

RELEASE OF ALL CLAIMS & MEDIA WAIVER

RELEASE OF ALL CLAIMS *

AGREE

I have read, understand, and agree to the RELEASE OF ALL CLAIMS outlined below.

In consideration for being accepted by Catholic HEART Workcamp L.L.C. (CHWC), a Florida limited liability company, I, being 18 years of age or older, do for myself and, if applicable, for and on behalf of my child-participant (if said child is not 18 years of age or older) do hereby release, forever discharge and agree to forever hold harmless Catholic HEART Workcamp and its managers, members, directors, officers, employees, and agents thereof, from any and all liability, claims, demands for personal injury, sickness, death, as well as property damage and expenses of any nature whatsoever, including, but not limited to, bacterial and viral diseases such as, but not limited to COVID-19 and any other infectious diseases, which may be incurred by the undersigned or the child participant resulting from participation in the above-described workcamp (including, but not limited to, travel between the child's home and the camp, free day activities, excursions from the camp, and anytime spent at the camp). Furthermore, I (and on behalf of my child-participant if under the age of 18 years), hereby assume all risk of personal injury, sickness, death, damage, and expenses as a result of participation as above set forth. Moreover, Catholic Heart Workcamp (CHWC) is not responsible for any injuries sustained by individuals or groups while swimming. Swimming is an activity that carries inherent risks, and participants assume all responsibility for their own safety while engaging in this activity. CHWC does not provide supervision or instruction for swimming activities, and it is the responsibility of each participant to take appropriate precautions and to swim at their own risk. CHWC will not be held liable for any injuries or damages that may occur as a result of swimming. Additionally, authorization and permission are hereby given to CHWC to furnish any necessary transportation, food, and lodging for and to assign work projects to this participant. The undersigned, on behalf of themselves and, if applicable, their child participant, further agree to hold harmless and indemnify Catholic HEART Workcamp and associated social agencies and daycare centers and their directors, officers, employees, and agents, for any loss, claim, liability, damage, including property damage or injury whatsoever incurred by child-participant as a result of the negligent, willful or intentional acts of said participant, including reasonable attorney’s fees and other expenses incurred attendant thereto.

I, as an adult, 18 years of age or older, if I am unable to speak for myself, hereby give my permission to CHWC to transport me to a doctor or hospital and hereby authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and I assume the responsibility of all medical bills and transportation costs. I also authorize the release of medical records to an attending physician in case of a need for medical treatment. Further, I hereby assume and indemnify Catholic HEART Workcamp, L.L.C. for all transportation or medical costs. I am aware of no physical, mental, or emotional problems, which would limit my participation in or work performance at CHWC. I am fully aware of the nature of the work to be undertaken during the Catholic HEART Workcamp.

If applicable, I, as the parent or legal guardian of this participant under the age of 18 years of age, hereby grant my permission for him (her) to participate fully in said workcamp, and hereby give my permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and I assume the responsibility of all medical bills. I give permission for my child to be transported in privately owned vehicles or in public transportation and for the release of medical records to an attending physician in case of a need for medical treatment. Further, should it be necessary for the participant to return home due to disciplinary action, for medical reasons, or otherwise, I hereby assume and indemnify Catholic HEART Workcamp, L.L.C. for all transportation costs. I am aware of no physical, mental, or emotional problems, which would limit participation in or work performance during the workcamp. I am fully aware of the nature of the work to be undertaken during the Catholic HEART Workcamp.

The Catholic HEART Workcamp will employ reputable staff members and take reasonable precautions to safeguard the CHWC participants during the week of the workcamp. However, neither the Catholic HEART Workcamp L.L.C., associated social agencies, nor the school acting as “home base” will be liable for loss or damage to property of participants prior to, during, or following the workcamp due to theft, fire, accident or any other cause beyond its control.

MEDIA WAIVER *

AGREE

I hereby authorize and give my full consent to Catholic HEART Workcamp L.L.C. to copyright and or publish any and all photographs, video or audio in which I/my child will appear in while attending Catholic HEART Workcamp. I further agree that Catholic HEART Workcamp may transfer these photographs, video or audio for use on the Catholic HEART Workcamp website and all promotional material.

SIGNATURE AGREEMENT *

AGREE

In signing this document, I acknowledge and represent that I am authorized to sign this document on behalf of the parties listed, I have read the attached Media Waiver and Release of All Claims, and agree to their terms.