Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

What volunteer activities interest you most?

Events | Buddy Walk, Seabreeze, etc.

Programs | Social Groups

Programs | Mom Support Group

Support | Prenatal Diagnosis Support for Parents

Support | School-Age Support for Parents

Support | Adult Support for Parents

Support | Administrative

Please indicate which days you are interested in volunteering *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Please indicate the times you are usually available to volunteer. *

Morning

Afternoon

Evening

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Volunteer Agreement *

I agree to serve as a volunteer and commit to the following: 1. To perform my volunteer duties to the best of my ability. 2. To respect those we serve. 3. To meet time and duty commitment, or to provide adequate notices so that alternate arrangements can be made. 4. To maintain open communication with my volunteer coordinator regarding any issues or concerns. 5. To adhere to rules and procedures, including confidentiality of agency and client information. I understand and agree that submitting this application form does not automatically register me as a FCDSN volunteer, and that there may be certain qualifications I must meet before I may begin volunteering, including, but not limited to the acceptance of established volunteer policies and procedures, and successful completion of a background check. I recognize and acknowledge that there are certain risks of physical injury to volunteers providing and/or engaging in volunteer activities, and I voluntarily agree to assume the risk of all injuries, death, damages, or loss, regardless of severity, that I may sustain as a result of such volunteer activities. I furthermore agree to waive and relinquish all claims I may have as a result of such volunteer activities against FCDSN, or any of FCDSN’s respective officers, employees, agents, and/or other volunteers, collectively or individually. By submitting this form, I attest that the information I have provided on the form is true and accurate to the best of my knowledge.

I agree

Photo Release *

I give FCDSN permission to take photographs and/or video of me, and I grant FCDSN full rights to use such photographs and/or video of me, and any reproductions or adaptations thereof, for fundraising, publicity or other purposes, including but not limited to the right to use them in printed and online publicity, social media, and press releases. Furthermore, I agree to release, defend, hold harmless and indemnify FCDSN from any and all claims involving the use of my picture or likeness.

I agree