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Waiver of Liability
Volunteer Agreement Consent Form

I give my consent to volunteer at the Women’s Lunch Place.  I agree to volunteer my services without expectation of monetary payment.  I understand that my work at the Women’s Lunch Place may involve exposure to physical activity, contact with persons who may have communicable diseases, and other potential risks of injury.  Having been made aware of these risks, I agree to assume full responsibility for any accident or injury that may occur to myself, or my property during the duration of my involvement with Women’s Lunch Place.  In addition, I release and discharge Women’s Lunch Place and any if its directors and employees from any and all liability for any such accident, injury or destruction of my property.

I further grant to the Women’s Lunch Place, my consent to use my name, photograph, image and voice in any and all media, publications, advertising and publicity, in connection to my participation with Women’s Lunch Place.  In addition, I agree to conduct myself in an orderly manner when volunteering at the Women’s Lunch Place.  I agree to maintain guests’ confidentiality, to abide by guidelines established by the Massachusetts Board of Health when preparing and serving food, and to follow additional rules established by the Women’s Lunch Place.  I understand that my failure to adhere to the aforementioned terms may result in disciplinary action or dismissal as a volunteer at Women’s Lunch Place.

I have carefully read this Agreement and fully understand its content.  I agree to abide by its terms and conditions.

Confidentiality Policy

Women’s Lunch Place respects the privacy and confidentiality of each woman who visits the shelter.  Guests are not required to disclose any personal information, including their name, to any staff and/or volunteer of the Women’s Lunch Place to receive services.  For those guests who do release personal information to staff and/or volunteers, staff/volunteers may not disclose or release this information about the guest(s) to any person within WLP or outside of WLP that does not have a “need to know” without the proper consent of the guest involved.

All discussions among staff and volunteers regarding guests must be conducted in a private setting and never in a public area.  If a staff or volunteer sees a guest(s) outside of the shelter and the guest shows an interest in communicating with the staff/volunteer, he/she may engage in a conversation.

All recording devices (e.g. cameras, tape recorders, video cameras, etc.) are prohibited from being used within the shelter without first obtaining permission from the guest, staff, or volunteer involved as well as the Program Director or the Executive Director.

Student interns whose academic program requires a paper on their experiences at the Women’s Lunch Place must not use any actual guest names, identifying information about the guest, or specific incidents in these papers.  Prior to commencing a paper or project about the Women’s Lunch Place and/or its guests, students must seek permission from the Executive Director or the Program Director.

My signature on this statement acknowledges my receipt of the Confidentiality Policy.  I understand that it is my responsibility to read and comply with this policy. 


Today's Date: January 14, 2025

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

For Company Volunteer Groups: What is your title (if applicable)?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Phone Number

Phone Number:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

For Company Volunteer Groups: What is your title (if applicable)?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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