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2. Name *

4. I certify that I am volunteering to assist the City of Jurupa Valley in various projects benefiting the City and its citizens.  I understand that my volunteering may include light physical activity and receiving instruction from City Staff for work on various City projects, events, or general assistance that will be assigned to me (the “work”).  I further certify that I am in good health and have no physical or other impediment which would endanger me while volunteering. In consideration for being allowed to volunteer for the City, I, the undersigned, acknowledge, appreciate and agree that: 

   1. Acknowledgement of Risks.  I understand that volunteering for the City is or may be dangerous and will or may involve risks of injury, loss, or damage to myself and/or any minor children for which I am responsible.  I further acknowledge that such risks may include, but not be limited to, bodily injury, personal injury, sickness, disease, death, and property loss or damage, arising from the work described above. 
   2. Workers Compensation Insurance.  I understand that I will be covered under the City’s workers compensation insurance program as a volunteer.  I agree to cooperate with the City and its worker’s compensation insurance carrier and worker’s compensation managers in the event of an injury. 
   3. Compliance with Terms and Conditions.  I agree to comply with the stated and customary terms and conditions for employees and volunteers in providing services and assistance for the City.  I agree to comply with all directions and orders of the City Staff with respect to my volunteer work.  I agree that all of the information I receive in the course of my work as a volunteer is confidential and that I agree not discuss this information nor release it to anyone without the express authorization from City Staff.  I agree that I am not an employee of the City and hereby waive all benefits that may be applicable to City employees, other than worker’s compensation.  I also agree that I can leave the volunteer program at any time and that the City can terminate my volunteer status at any time, with or without cause.  

8. I HAVE READ THIS VOLUNTEER REGISTRATION AND AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

10. Full Name Authorization*

    This will serve as your electronic signature.

11. Date of Authorized Submittal*
    Date of Authorized Submittal

13. EMERGENCY CONTACTS

15. Name*
16. Phone Number*
18. Name*
19. Phone Number*

21. FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

    This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her participating as a volunteer and agree to the terms and conditions of this Volunteer Registration and Agreement on his/her behalf, as provided above, and for myself, my heirs, assigns, personal representatives, executors, administrators, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liabilities incident to my minor child’s involvement in this class as provided above, whether arising from the negligence of the Releases or otherwise, to the fullest extent permitted by law. 

23. Parent/Guardian Name
24. Phone Number
26. Full Name Authorization

    This will serve as your electronic signature.

27. Minor Participant Name
29. Date of Authorized Submittal
    Date of Authorized Submittal

31. EMERGENCY CONTACTS OTHER THAN PARENT/GUARDIAN

33. Name
34. Phone Number
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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