Point-in-Time Count Registration

Question Title

* 1. Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

Question Title

* 2. Date of Birth

Must be 18 years of age or older

Date

Question Title

* 3. Have you previously participated in the Polk County Point-in-Time count?

Yes

Question Title

* 4. Though not guaranteed, is there a specific geographic location that you prefer? (i.e., Lakeland, Ft. Meade, Mulberry, etc.)

Question Title

* 5. Though not guaranteed, is there a specific organization, team, or individual that you would like to work with on the day of the PIT count?

Question Title

* 6. Do you know of any encampments or areas around Polk County to which volunteers should look for unsheltered individuals?

Question Title

* 7. Do you have lived experience of homelessness?

Volunteer Release:

By signing below, I understand that I represent the Lakeland, Winter Haven/Polk County Continuum of Care and that I am over the age of 18. I hereby agree to hold harmless and release the Lakeland, Winter Haven/Polk County Continuum of Care; its member organizations, their boards/trustees, employees, volunteers, count organizers; and other participants in the Florida Point-In-Time Count from any liability for any accident, illness, injury or death or any theft or loss of property arising from the participation as a Volunteer in the Point-In-Time Count, regardless of whether incurred as a result of negligence or other. I voluntarily assume these and any other risks in participating in the count and waive all claims and causes of action that may arise out of participation in the count.

I have agreed to serve as a volunteer for the Florida Point-In-Time Count. I understand that as a volunteer for the Point-In-Time Count it will be necessary for me to handle and process confidential information. I acknowledge that I will keep all information confidential while a volunteer and that it is my responsibility to keep this information confidential even after I end my volunteer duties for the Point-In-Time Count. I understand that I am not to disclose any identifying confidential information and/or records or to engage in casual or informal conversation identifying any individual involved in the count.

I have read and fully comprehend the information pertained in this form and agree to the terms of this release. By signing below, I acknowledge that it is my responsibility to comply with all relevant laws, policies, and regulations concerning access, use, maintenance and disclosure of information made available to me as a volunteer in the Point-In-Time Count.

Question Title

* 8. Enter your first and last name to confirm you have read and agree to the above Volunteer Release statement.

Please be on the lookout for an email regarding training dates.

Thank you for helping us make sure that EVERYONE COUNTS!