VBS 2020 Volunteer Release and Screening

Please provide all information. A separate registration MUST be filled out by EACH worker in your family

REGISTRATION

Name

Address

Home Phone

Mobile Phone

This address will receive a confirmation email

EMERGENCY CONTACT INFORMATION

First Contact Name

First Contact Phone

Scond Contact Name

Second Contact Phone

*BY CHECKING EACH OF THE FOLLOWING BOXES, I AM PROVIDING INFORMATION TO THE BEST OF MY ABILITY AS WELL AS ACKNOWLEDGING AND AGREEING TO THE TERMS OF EACH STATEMENT

MEDICAL INFORMATION AND SCREENING

Medical or other information that we may need to know. Please include any food allergies. Enter 'NONE' if there is no medical information that we need to know.

I attest that as of the date of this registration

I nor anyone in the home are experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. I nor anyone in the home has traveled internationally within the last 14 days. I nor anyone in the home has been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities. To the best of my knowledge; I nor anyone in the home has been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. If any of the above situations change, I will notify the Church.

ACKNOWLEDGMENT

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities recommend practicing social distancing and other measures to avoid the contact and spread of the disease.

I further acknowledge that Faith Baptist Church of Belle Valley has put in place preventative measures to reduce the contact and spread of the Coronavirus/COVID-19.

I further acknowledge that Faith Baptist Church of Belle Valley cannot guarantee that I will not become infected with the Coronavirus/Covid-19.

RELEASE OF LIABILITY

I hereby release and agree to hold Faith Baptist Church of Belle Valley harmless from, and waive on behalf of myself, my heirs, my dependents, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Church, or that may otherwise arise in any way in connection with any activities of Faith Baptist Church of Belle Valley.

I understand that this release discharges Faith Baptist Church of Belle Valley from any liability or claim that I, my heirs, my dependents, or any personal representatives may have against the Church with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any activities of Faith Baptist Church of Belle Valley. This liability waiver and release extends to the Church together with all staff and volunteers.

*BY ENTERING MY FULL LEGAL NAME IN THE BOX BELOW, I AM PROVIDING MY DIGITAL SIGNATURE FOR PERMISSION AND CONSENT.

SIGNATURE

*Electronic Signature

VBS 2020 Volunteer Release and Screening

Description

Please Fix the Following