GLOW Volunteer Interest Form

Join the family at GLOW and help us transform our community, one girl at a time.

Name*	Address*
Phone*
Email*
Confirm Email*
Emergency Contact*Whom should we contact in case of an emergency?	Emergency Contact Phone Number*
Can you successfully pass a background check?* Yes No	Are you CPR certified?* Yes No
Professional Experience Please tell us a pttle bit about you and your professional experience.	Please select the option that best fits your current occupation. ** Employed Student Retired
Describe your formal/informal training and experience pertinent to the volunteer services you would provide.*	List hobbies or special skills.*
Volunteer Interest	Please indicate your volunteer interests, check all that apply ** Tutoring Special Events (Learning Circles, Festivals, etc.) Classroom Fieldtrip Chaperone Administrative Duties - Office Help Manual Labor (Cleaning, Painting, Landscaping) Church Outreach Program Spanish Interpreter Lunch/Recess Other Area of Interest

When are you able to volunteer?*

MONDAY AMMONDAY PMTUESDAY AMTUESDAY PMWEDNESDAY AMWEDNESDAY PMTHURSDAY AMTHURSDAY PMFRIDAY AMFRIDAY PMWEEKENDSEVENINGSALL OF THE ABOVEOTHER

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This Waiver of Liability (the "Waiver") executed by the Volunteer in favor of GIRLS LEADERSHIP ACADEMY OF WILMINGTON (GLOW) and/or GLOW FOUNDATION, nonprofit corporations organized and existing under the laws of the State of North Carolina.

I, the Volunteer, desire to work as a volunteer for GLOW and/or GLOW Foundation and engage in the activities related to being a volunteer.

I hereby freely and voluntarily, without duress, execute this Waiver under the following terms:

1. Waiver and Release. I, the Volunteer, release and forever discharge and hold harmless GLOW and/or GLOW Foundation and its successors and assigns from and all liability, claims and demands of any kind or nature, either in law or in equity, which arise or may hereafter arise from my volunteer work with GLOW and/or GLOW Foundation. I understand and acknowledge that this Waiver discharges GLOW and/or GLOW Foundation from any liability or claim that I, the Volunteer, may have against GLOW and/or GLOW Foundation with respect to bodily injury, personal injury, illness, death, or property damage that may result from my participation with GLOW and/or GLOW Foundation . I also understand that GLOW and/or GLOW Foundation does not assume any responsibility for or obligation to provide financial assistance or other assistance, including not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage.

2. Insurance. I, the Volunteer, understand that I expressly waive any such claim for compensation or liability on the part of GLOW and/or GLOW Foundation.

3. Medical Treatment. I hereby release and forever discharge GLOW and/or GLOW Foundation from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency or injury during my time with GLOW and/or GLOW Foundation.

4. Confidentiality. Confidentiality is of the utmost importance in the volunteer's association with program participants. Any information, data or behaviors observed by the volunteer is confidential. Information observed by volunteering shall not be discussed with anyone outside of GLOW and/or GLOW Foundation setting. Information shall not be shared without use of the student's name because it is possible that information could still be linked to the student.

5. Photographic Release. I grant and convey unto GLOW and/or GLOW Foundation all right, title, and interest i any and all photographic images and video or audio recordings made by GLOW and/or GLOW Foundation during my work for GLOW and/or GLOW Foundation, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

6. Other. I expressly agree that this Waiver is intended to be as broad and inclusive as permitted by the laws of the State of North Carolina, and that this Waiver shall be governed by and interpreted in accordance with the laws of the State of North Carolina. I agree that in the event that any clause or provision of this Waiver shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable.

Name* First Middle Last Suffix

Other Names/Maiden/Alias

Date of Birth*	Social Security Number*	Driver's License Number* Please include state abbreviation
Phone*	Email*	Organization (if applicable)

Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Present Address

Consent* Consent *This information will be used for background screening purposes only and will not be used as hiring criteria. I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me.

Electronic Signature*

Please type your name here. This online signature is required.

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