First Name Last Name
Email
Cell number. *In case we need to communicate with you during the event. Your number will not be shared with anyone else.*
Emergency contact first and last name.
Emergency contact phone number.*
COVID-19 Liability Waiver I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that After The Peanut has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that After The Peanut can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, After The Peanut staff, and other volunteers or guests. I voluntarily seek services provided by After The Peanut and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while my volunteering shift. I attest that: *I am not experiencing any symptoms 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 have not traveled internationally within the last 14 days. *I have not traveled to a highly impacted area within the United States of America in the last 14 days. *I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. *I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities. I am following all CDC-recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold After The Peanut harmless from and waive on behalf of myself, my heirs, 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 any act may cause, or failure to act of After The Peanut, or that may otherwise arise in any way in connection with any services received from After The Peanut. I understand that this release discharges After The Peanut from any liability or claim that I, my heirs, or any personal representatives may have against the organization with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from After The Peanut. This liability waiver and release extends to the organization together with all owners, partners, and employees. I have read, understand, and agree to the terms of the COVID-19 Liability Waiver. In Case of Emergency - In case of emergency employees or volunteers of After The Peanut will take on the responsibility of providing any non-emergency medical attention that is necessary and if an emergency occurs 911 will be contacted immediately and the parent or guardian or contact who is in our system will be contacted directly after 911. I authorize After The Peanut to provide simple medical attention for myself or my child for minor incidents that may arise from participating in their volunteer activities and on my behalf, and on behalf of my child, I hereby release, covenant not to sue, discharge, and hold harmless After The Peanut, its employees, volunteers, agents, and representatives, of and from claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising from personal injury, illness, permanent disability, or death. Yes, I agree and authorize.No, I do not agree or authorize.
Media Release - After The Peanut may use images of volunteers for future promotion materials including brochures, video, website and other lawful uses. I acknowledge that there is no agreement or promise on the part of After The Peanut, to compensate volunteers or parents in any way for the use of the photograph/image/video in said manner. I hereby release After the Peanut from any and every claim of whatever kind or nature, either in law or equity, arising from the use of photographs and images. Yes, I agree to the Media Release.No, I do not agree to the Media Release.
Are you under the age of 18? (If yes, please have your parent/guardian complete the following section.) YesNo
How did you hear about us? School/WorkCommunity EventFriend/RelativeSocial mediaOther
