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James River Association
Volunteer
Sign-In Sheet, Waiver & Health Form

 

ALL JRA EVENT PARTICIPANTS (AND/OR THEIR GUARDIANS) PLEASE READ AND SIGN THE FOLLOWING: 

All of the above information is to the best of my knowledge, correct. I understand that participation in James River Association (JRA) activities is entirely voluntary. I understand that the JRA event may involve “hands on” activities such as planting, picking up trash, using equipment, or wading in shallow water; and I understand the risks and dangers involved in the above-named activities. I know and understand that unanticipated dangers might arise. I, being of lawful age, on behalf of myself, my personal representatives, heirs and next of kin hereby release and forever discharge JRA, its Board of Directors, agents and employees (all hereinafter referred to as releasees) from any and all liability or responsibility for injury to person or property which might occur as a result of participation in JRA activities, whether caused by the negligence of the releases or otherwise. I further agree to indemnify, defend, save and hold harmless the releasees from any loss, liability, damage or cost I may incur. I agree that this release and indemnity agreement is intended to be as broad and inclusive as is permitted by laws of the Commonwealth of Virginia. I give permission to authorize personnel to carry out such emergency diagnostic and therapeutic procedures as may be necessary for me / my child, and also permit such treatment procedures to be carried out at and by local hospital(s) for me / my child in the event of an emergency. I understand that any medical expenses will be billed directly to me or my insurance company. I hereby grant the JRA the unconditional right to use my / my child’s name, voice, and photographic likeness in connection with any audio video production, articles, website materials or press releases, but not as an endorsement. Under no circumstances will a name be used in conjunction with an image or voice without prior consent.

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
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
Check to receive information and news from the James River Association
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's 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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Health Concerns: Please list any allergies, health problems, or special needs pertaining to the participant, such as asthma, diabetes, allergic to bee stings, etc.
Check here if you do NOT want you/your child's name, voice or photographic likeness to be used.
Please DO NOT share
Which program are you participating in?
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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