Cornerstone Wellness Center, Inc

Cornerstone Wellness Center, Inc.Mail completed form Volunteer Application To:

120 W. Washington St.,

Suite 3-B

Medina, Ohio 44256

Fax: 330-725-5792

Name: ______

Address: ______

City: ______County: ______Zip: ______

Email address: ______

Phone: ______

Date of birth: ______Social Security #: ______

AGE: ______Male/female

Please indicate your availability:

(please let us know if you prefer regularly scheduled events/short notice/days/evenings)

Are you interested in volunteering regularly or only as needed? What time commitment are you willing to invest?

What interests/experience do you possess that will help our organization?

What experiences would you like to gain from volunteering?

How did you hear about our organization?

Please list your other volunteer experience:

Have you ever been convicted of a felony? ____Yes ____No (Prior convictions do not necessarily exclude you from a volunteer experience)

If yes, please state the type of offense and when it occurred: ______

______

Do you consent to a routine background check? Yes______No______

Do you have any physical limitations/restrictions/special needs?

(Please also indicate any allergies, medical conditions, and medications)

Emergency contact information:

In the event of an emergency please provide the following information:

Emergency contact person: Name: ______Phone: ______

Relationship: ______

Preferred doctor: ______Phone: ______

Preferred hospital: ______Phone: ______

Permission to provide medical information, if needed to EMS? Yes _____ No_____

Please provide two character references (employment, social, or volunteer related) Please do not list relatives/family members.

Name: ______Phone ( )______Relationship: ______

Name: ______Phone ( )______Relationship: ______

I authorize the contact of listed references and I understand that the misrepresentation of omission of any information requested is grounds for non-appointment and/or dismissal as a Cornerstone Wellness Center, Inc volunteer.

As a volunteer of Cornerstone Wellness Center, Inc. I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury, or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward.

Signature______Date ______

All information obtained from this application will be considered confidential

Waiver and agreement

I do herby, for myself, my heirs, executors, and administrators waive and discharge the Medina Food Bank and Cornerstone Wellness Center, Inc. and all its officers, agents, and employees from and against any and all claims, demands, actions or cause of action arising from any injuries or damages I may suffer or sustain by my participation in any activity for which I participate in for the Medina Food Bank. Furthermore, in full recognition and appreciation of the potential dangers and hazards inherent in such an activity, I do hereby agree to assume all the risks and responsibilities surrounding my participation in this activity or any activities undertaken in addition thereto. I also understand that the completion of this application does not guarantee placement within the volunteer program.

Signature______Date______