Loading...

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

 

With the recent challenges posed by COVID-19, the James River Association is asking participants to help us run programs as safely as possible. Please know that the risk of exposure to the COVID-19 virus cannot be completely eliminated. JRA asks each participant to fully evaluate your ability and willingness to participate in guidelines and understand the risks. 

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

I understand and agree that I will not participate in this activity if I have experienced any of the following symptoms in the 14 days prior to this activity: new or worsening cough; shortness of breath or difficulty breathing; fever greater than 100.4ºF; chills; unexplained muscle pain, sore throat, new loss of taste or smell. I also agree that no one in my household has exhibited the above symptoms or that I have knowingly been in contact with anyone with confirmed COVID-19 in 14 days prior to this activity.

 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*
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*
Second Participant's 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*
Third Participant's 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*
Fourth Participant's 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*
Fifth Participant's 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*
Sixth Participant's 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*
Seventh Participant's 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*
Eighth Participant's 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*
Ninth Participant's 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*
Tenth Participant's 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
A signed copy of this waiver will be sent to the email address you provide.
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*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!