The Volunteer Center of Napa Valley

1820 Jefferson Street
Napa, CA 94559
707-252-6222

~~ Feel fee to copy, fill out, and return to the Volunteer Center (fax: 226-5179) ~~

Be a part of Napa’s Second Project Homeless Connect

Wednesday, September 29, 2010

Volunteer Application Form

Name:

First M. I. Last

Best time to contact:

e-mail address:

Contact Phone:

Mailing address:

Street Address City Zip

I am available on 9/29: o All Day (8a.m. to 5) o 8 to 12 p.m. only o Noon to 5 and/or oTo help set up on 9/28 (hours TBD).

I would like to volunteer:

o Where I am needed most

o As a greeter (10 needed)

o As a helper with a service provider

o As a welcome concierge

(10 needed/outside work)

Other:

o As a guide (300 needed)

o As a Spanish Speaking Guide

o As a Spanish translator (10-15 needed)

o I have a service/skill to offer:

T-Shirt Size: o Small o Medium o Large o XLarge o XXLarge

Any other information to help us find the best opportunity for you:

Return this form to:

Katie Meehan-Rubin, 252-6222 or katier@volunteernapa.org

at the Volunteer Center of Napa Valley

~~~~~~~~~~~~~~~~~~~

City of Napa

OATH OF CONFIDENTIALITY

Community Action of Napa Valley (CANV) and all participating agencies respect the privacy and privacy rights of the people we serve.

I understand that:

1. The purpose of gathering and sharing private information between survey and service team members of the Homeless Project Connect is to improve housing and health outcomes for the clients served at Project Homeless Connect.

2. Sharing of personal client information will be limited to that which will help achieve this purpose.

3. The unauthorized release of any protected health information may make me subject to a civil action for damages. In addition, Federal and State laws protecting information relating to the provision of confidential patient information, including, but not limited to, mental health and substance abuse information may apply. These laws may have additional penalties, including criminal penalties.

_______________________________________________

PRINT NAME

_______________________________________________ ______________

SIGNATURE Dated

(parent signature if under 18)

Reference:

· California Welfare and Institution Code, Section 5328, Chapter 3 commencing with Section 525 of Title 7 of Part 2 of the Code of Civil Procedure; and

· Title 9, California Administrative Code Section 942, Oath of Confidentiality

CONSENT TO PARTICIPATE AND RELEASE OF LIABILITY

I, __________________________________ understand that I am participating in activities related to Project Homeless Connect by my own choice.

I agree to release Community Action of Napa Valley (CANV), the Volunteer Center of Napa Valley and Napa Valley Expo from any liability for any injury or illness to me during my participation with Project Homeless Connect. I assume full responsibility for risk of bodily injury or property damage incurred by myself arising either directly or indirectly from participation in Project Homeless Connect, from any cause whatsoever.

I understand this release extends to claims that I do not know or do not expect to exist at the time of the signing of this release and I hereby waive the protections of California Civil Code Section 1542.

I agree to indemnify, defend and hold harmless the City for any liability that may arise as a result of my criminal, willful or fraudulent acts or omissions that occur during my participation in Project Homeless Connect.

I agree to return all forms and data sheets to Project Homeless Connect staff upon completion of my participation in Project Homeless Connect.

_____________________________________ __________________________________

Name (print) Signature

Parent/Guardian if under 18 _____ / _____ / _____

~~~~~~~~~~~~~~~~

CONSENT TO PHOTOGRAPH

I hereby authorize Community Action of Napa Valley (CANV), the Volunteer Center of Napa Valley and all participating agencies to photograph or permit other persons to photograph me. I agree that they may use or permit other persons to use the negatives or prints prepared there from for such purposes and in such manner as may be deemed necessary (most likely, for newspaper publicity or to create a slide show for presentations to groups).

___________________________________ _________________________________

Print Name Signed

Date _________ Hour _________ Witness_____________________________