CHARLEY'S ANGELS TEAM FLORIDA VOLUNTEER CHAPLAIN APPLICATION (Must be 18 Years or Older) Full (Legal) Name

Transcription

1 CHARLEY'S ANGELS TEAM FLORIDA VOLUNTEER CHAPLAIN APPLICATION (Must be 18 Years or Older) Full (Legal) City State Zip Code Phone (work) (home) (cell) Marital Status: Married Single Divorced Separated Widow/Widower Emergency Contact Phone Church Affiliation May we contact your Senior Pastor as a reference? If yes, Pastor s name and contact information: : Telephone: Church : City: State: 1. How did you hear about Charley's Angels? Date of Application 2. Why do you desire to serve as a Volunteer Chaplain? 3. Please circle (letter) the ministry role(s) you have served in the past. Ministry Role Years of Service a. Pastoral a ministry to pastors b. Chaplain FBI, Police, Fire or Military c. Christian Counseling (Licensed/Certified) Specify: adult, youth, children d. Trainer Crisis Intervention, Clinical Trauma or Disaster Response e. Children s Ministry working with children

2 f. Youth Ministry working with youth g. Hospice Worker h. Street ministry and other general assignments i. Administrative Support J. Prayer Intercessor K. Marriage Ministry L. Other (please describe): 4. Please describe past training and experience in disaster response, grief, trauma or crisis intervention. 5. Please check one or more boxes below that best describes your ministry training or vocational experience: Law Enforcement Fire Military Personnel EMS CERT VIPS Christian Counselor Pastor Hospice Worker Chaplain Ministry Leader Trained in Crisis Intervention 6. Do you have any physical, emotional or medical limitations that would hinder your involvement in a disaster site? If so, please explain. 7. Please check below the boxes of the conditions or situations which would be acceptable to you in a deployment: Climb stairs Sleep on cots Lift 25 lbs. No electricity Extreme weather conditions (below 25 degrees F or above 95 degrees F) Work 8-12 hours per day Extended times standing or walking Assist with daily chores (cleaning, laundry, etc.) 8. On the scale below, please circle the number that best describes your comfort level to share God s love and comfort with others Not Comfortable Very Comfortable

3 9. If sent to a disaster, would be able to deploy for one week? Yes No 10. If deployed would you be able to cover your own travel expense? Yes No 11. Would you be flexible to travel within a 24-hour notice? Yes No 12. Do you have: Valid Driver s License? Yes No 13.Commercial Driver s License? Yes No 14. Please list any additional information we should know about your background or qualifications. (Use additional paper if needed.) 15. List any languages you speak in addition to English (including sign language). 16. Please list five references we may contact: (i.e. friends, business associates, pastor on church staff etc. Please do not include family members or Senior Pastor listed above. Must have known for at least 6 months.) Phone Phone

4 Phone Phone Phone 17. Please describe below any crisis or time of grief you have personally experienced in the past months. (Optional) PLEASE MAIL Charley's Angels Team Florida Attention: Emotional and Spiritual Team 2398 Commercial Way # 214 Spring Hill, Fl 34606

5 Charley s Angels Team Florida Inc. Release and Waiver of Liability PLEASE READ CAREFULLY! THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS! This Release and Waiver of Liability (the Release ) is executed on this day of 20. By (the Volunteer), and if applicable, in conjunction with, the parent having legal custody or the person having legal guardianship of the Volunteer, in favor of Charley s Angels a Florida non-profit corporation, its directors, officers, volunteers, members, employees, agents, successors and assigns. The Volunteer desires to work as a volunteer for Charley s Angels and engage in the activities related to being a volunteer. The Volunteer understands that the activities may include constructing and rehabilitating residential buildings, working in and around disaster areas and living in housing provided for volunteers of Charley s Angels. The Volunteer does hereby freely, voluntarily and without duress execute this Release under the following terms: 1) Waiver and Release. The Volunteer does hereby release and forever discharge and hold harmless Charley s Angels and its directors, officers, volunteers, members, employees, agents, successors and assigns from any and all liability, claims and demands of any kind or nature whatsoever either in law or in equity, which arise or may hereafter arise from Volunteer s work for Charley s Angels. The Volunteer understands and acknowledges that this release discharges Charley s Angels for any liability or claim that the Volunteer may have against Charley s Angels with respect to any bodily injury, personal injury, illness, death or property damage that may result from the Volunteer s work for Charley s Angels, whether caused by the negligence of Charley s Angels or its officers, directors, volunteers, members, employees, or agents, or otherwise. The Volunteer also understands that, except as otherwise agreed to by Charley s Angels in writing, Charley s Angels does not assume any responsibility for or any obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of bodily injury, personal injury, illness, death or property damage. It is the Volunteer s express intent that this Release and Waiver of Liability shall bind Volunteer s family members, spouse, heirs, assigns and personal representatives. 2) Minors. It is the policy of Charley s Angels that no minor under the age of 14 years shall be allowed on any site while there is construction in progress. Minors between the ages of 14 and 15 years are prohibited from performing any general construction work, in compliance with applicable federal regulations, but may perform limited activities such as landscaping or painting. Minors between the ages of 16 and 17 may perform general construction work, but may not engage in ultra hazardous activities, such as use of power tools and motor vehicles, demolition, excavation and roofing. 3) Medical Treatment. Except as otherwise agreed to by Charley s Angels in writing, the Volunteer does hereby release and forever discharge and its Charley s Angels directors, officers, volunteers, employees, agents, successors and assigns from any claim whatsoever that arises or may hereafter arise on account of any first aid treatment or service rendered in connection with the Volunteer s work for Charley s Angels. 4) Assumption of the Risk. The Volunteer understands that the work for Charley s Angels may include activities that are hazardous to the Volunteer, including but not limited to construction,

6 loading and unloading and transportation to and from the work sites. In connection thereto, the Volunteer recognizes and understands that activities at Charley s Angels may in some situations involve inherently dangerous activities. The Volunteer hereby expressly and specifically assumes the risk of bodily injury, personal injury, illness, death or property damage arising out of these activities and releases Charley s Angels and its directors, officers, volunteers, members, employees, agents, successors and assigns from all liability for any and all such injury, personal injury, illness, death or property damage. 5) Insurance. The Volunteer understands that except as otherwise agreed to by Charley s Angels in writing Charley s Angels does not carry or maintain health, medical or disability insurance coverage for any Volunteer. Each Volunteer is expected and encouraged to obtain his or her own insurance coverage. 6) Photographic Release. The Volunteer does hereby grant and convey unto Charley s Angels all right, title and interest in any and all photographic images and video or audio recordings made by Charley s Angels during the Volunteers work for Charley s Angels including but not limited to any royalties, proceeds or other benefits derived from such photographs or recording. 7) Indemnification and Hold Harmless. The Volunteer agrees to indemnify and hold harmless Charley s Angels and its directors, officers, volunteers, members, employees, agents, successors and assigns from any claims, costs, damages or expenses resulting from any bodily injury, personal injury, illness, death or property damage arising out of the Volunteer s work for Charley s Angels. 8) Other. The Volunteer expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Florida. Volunteer agrees that in the event that any clause or provision of this Release 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. IN WITNESS WHEREOF, the Volunteer has read, understood, and executed this Release as of the day and year first above written. Printed name of Witness Signature of Witness Printed name of Volunteer Signature of Volunteer Print Full Home Phone Cell Age of Volunteer: years Printed of Parent/Guardian (if applicable)