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If you are 17 years or younger, please provide parent or legal guardian's name and phone number (required for participation). If you are 18+ and would like to provide the information for an emergency contact, please do so here; otherwise, write "N/A."
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Do you require community service hours?
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Administrative Assistance
Cold Night Shelters (November - March)
Create Social Media Content
Group Volunteer Events
Host a Donation Drive
Package and Deliver Resources and Supplies
Point in Time Count and Survey (January)
Share Events, Information, and Resources
Translation Services
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By completing this document you waive certain rights including the right to sue. Please read the following carefully, and please check each box noting that you understand and agree to the terms of the waivers and releases below.
The undersigned (including the parent or guardian of any minor) and his/her/their heirs, devisees, representatives, spouses, family relations, successors, and/or assigns (collectively, the “Signer”) is aware that engaging in activities or services (“WORK”) on behalf of HOMELESS LEADERSHIP ALLIANCE OF PINELLAS. (collectively, the “Charity”) may involve certain risks, dangers and hazards, including, but not limited to, picking up dangerous debris and collision with passing traffic. The signer represents and warrants that he/she/they are fully, physically, and medically capable of properly performing the Work and will immediately notify the Charity of any ailment, condition, or inability to the contrary.
Safety and Claims. Signer agrees to wear a safety vest and use proper tools (such as gloves, tongs, protective eyewear, and/or EZ Reacher’s) while participating in the Work to minimize any such risks and freely accepts, and fully understands and assumes all risks and dangers and the possibility of personal injury, death, property damage, or loss resulting from the Work including NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE.
Signer agrees to indemnify and hold the Charity, its members, officers, agents, employees, attorneys, and any person or entity acting on its behalf harmless from and against any and all claims, injuries, damages, costs, expenses, attorney fees, and/or medical fees or expense in performing the Work. Any action between Signer and the Charity shall be in Pinellas County, Florida where exclusive venue rests with Florida law being applicable to all matters between Signer and the Charity.
Photo, Video, Statement and Endorsement Release Form. I hereby irrevocably grant all rights, title and interest and give permission to the Homeless Leadership Alliance of Pinellas, and its directors, officers, employees, licensees, successors and assigns, to use, reproduce, distribute, publish and copyright photographs and/or video of me taken during volunteer events for any purpose in any and all media now known or hereafter developed, including but not limited to use in publications, news releases, online, and in other communications related to the mission of the Homeless Leadership Alliance. I hereby hold harmless and release and forever discharge the Homeless Leadership Alliance of Pinellas from all claims, demands, damages and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I understand that nothing herein obligates the HLA to use my name or photograph(s) or video in any advertising materials.
Non-Proselytizing Agreement. In order to maintain a safe, conflict-free environment, and to abide by the principles and mission of the HLA. The mission of the HLA is to strive to prevent, divert, and end homelessness in Pinellas County by providing leadership to community partners and stakeholders in the planning, implementation, and alignment of the community-wide crisis response system. The vision of the HLA is to ensure that homelessness is rare, brief, and a one-time experience.
Non Disclosure Agreement. Confidential Information. All data, materials, knowledge and proprietary information generated through, originating from, or having to do with the Charity or persons associated with its programs, activities, including contractors, is to be considered Confidential Information and is not to be disclosed to any outside party. This includes, but is not limited to, hearsay, documents, information, system data, designs, printed matter, policies, procedures, conversations, messages (received or transmitted), resources, contacts, email lists, email messages, whether internally between staff or outside the Charity is confidential and the sole property of the Charity. Clients. Client information, including all file information, is not to be disclosed to any third party, under any circumstances, without the written consent of the Company and the client. Damages. Any disclosure, misuse, copying or transmitting of any material, data, or information, whether intentional or unintentional, will subject Signer to disciplinary action, prosecution, and/or monetary damages according to the procedures set by Company and any applicable laws.
By checking this box and submitting this form, you are acknowledging that you have read the above waiver and agree to its terms.
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